Get Tx Advanced Spine Care Of Texas Spine Evaluation Form

Completing the TX Advanced Spine Care Of Texas Spine Evaluation Form online is an essential step in receiving proper evaluation and treatment for spine-related issues. This guide provides clear, step-by-step instructions to help users accurately fill out the form with ease and confidence.

Follow the steps to effortlessly complete your spine evaluation form.

1. Press the ‘Get Form’ button to obtain the evaluation form and open it for editing.
2. Begin by entering your personal information, including your name (last, first, and middle initial) and your dominant hand.
3. In the chief complaint section, indicate the specific part of your spine that is causing concern by checking the relevant box — low back/legs, neck/arms, or thoracic/upper back.
4. Provide details about the onset of your spine problem, including when your current symptoms began and any preceding events that may have contributed to your condition.
5. Answer questions regarding the changes in your symptoms since they began and whether you have experienced prior episodes of this condition.
6. Indicate if your issue is the result of an on-the-job injury by checking ‘Yes’ or ‘No’ and provide the estimated date of injury.
7. Use the pain diagram to accurately draw the locations of your symptoms on your body, utilizing the specified symbols for various pain sensations.
8. Rate your pain levels for back/neck and leg/arm pain over the last two weeks on a scale from 0 to 10.
9. Complete the section regarding how various activities affect your pain, including sitting, walking, lying down, and bending.
10. Check any conditions that apply to you concerning bladder function, bowel function, sexual function, sensation, and pain during nighttime.
11. List any previous treatments or consultations regarding your spine problem along with their effects.
12. Provide details of any physicians you have seen for this issue, along with their specialties.
13. Share any medications you have tried relating to your spine condition.
14. Complete the detailed function section by marking your pain intensity, experiences with personal care, sleeping, employment, lifting, social life, walking, sitting, and traveling.
15. For patients with scoliosis, answer specific questions regarding family history and growth.
16. Fill out the family health history section by indicating any relevant conditions among blood relatives.
17. Lastly, include the date of your last physical exam and the name of your primary care physician.

Complete your TX Advanced Spine Care Of Texas Spine Evaluation Form online today to ensure timely and effective care for your spine condition.