Uec. 11. 2013 3:06PM Stmcraz \ 7288 P. 1 Mount Asnnani Professor, ursnoprthths thageg Spine Surgery, Moont Sinai Hospital Chief of Spare Trauma, Bathurst Hospital Sinai Lehi & Peter W. May Department of Orthopaedic 5ursery The Mount Sinai Medical Center One Gustave I. Levy Place, Box 1148 New York, NY 10029-6574 ' Tel Ext Name: Date: DOB: Referring Physician: Primary Care Physician: Location of pain (circle all that apply): Neck Pain Upper Extremity Pain Mid Back Paln Dominant Hand (circle one): Right Left Review of Systems [Please check all items you feel are applicable to you]: _ Recent Infection _ Fever or chills _Weight Loss _ Difficulty Hearing Arm numbness _ Leg numbness _ Genital numbness _ Cough _ Bowel incontinence _ Change In appetite _ Bladder Incontinence _ Shortness of breath _ Fatigue — Headaches _ Poor Sleep — Muscle weakness ___ Swollen glands _ Sore throat _ Eye pain _ Severe nighttime pain _Sinusitis _ Cold hands/feet _ Hoarse voice _ Cough blood _ Anemia _ Bronchitis _ Leg swelling _ Loss of vision — Pneumonia _ Palpitations _ Asthma _ Ringing in ears _ Murmur _ Double vision _ Chest pain _ Sputum — Ulcer _ Indigestion _ Blood in stool _ Limited motion _ Constipation ___ Pain on urination Blood In urine _ Muscle aches _ Moult urination _Kidney stones _Swollen joints _ Thyroid problem _ Kidney Infection Red joints ___ GOUT _ Painful Intercourse _Arthritis Dry mouth _ 3itteriness _ Rash _ Dry, eyes _ Cold Intolerance _ Vulvar pain _ Nausea ^ ,atess sweating _ Painful periods _Prostate enlargement _ Abdominal pain Low Back Pain Lower Extremity Pain EFTA00283637