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200, 1402 8th Avenue N.W.
Calgary, AB T2N 1B9
Phone: 403.452.4798
Fax: 403.452.0995
COVER PAGE
Attention:
Name:
______________________________________________________________
FROM:
CALEO Health Spine
Spine Assessment Questionnaire
Booking Coordinator – Caleo Health (403) 452-4798
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We ask that you DO NOT send your medical information via
standard email this is not secure and doing so is at your own
risk. Caleo Health does not take responsibility for any
information you may attempt to transmit via standard email
Dear Patient The questionnaire should be completed and mailed to
Caleo Health along with your payment. Payment may be made by money
order or bank draft for $250.00 payable to: Caleo Health. If you
select to return your questionnaire by fax or secure-email you may
complete your payment by credit card over the phone. (Please note
we do not accept personal cheques). To Avoid the Rebooking fee of
$100.00 A Minimum of 48 hours notice is required for all Changes or
Cancellations of appointments. A $20.00 administration fee will be
applied for all refunds. There are NO Refunds for no show or late
cancellation of appointments. REFUND POLICY: ALL REFUNDS ARE
SUBJECT TO A $20 ADMINISTRATION & PROCESSING FEE. Refunds will
not be issued after 90 days of the initial payment date. No refunds
will be issued for appointments missed or cancelled within 24 hours
of the appointment date. No refunds will be issued after you have
received your Spine Assessment. Secure-Mail:
[email protected] Credit card payments can be made over
the phone: (403) 452-4798 Fax: (403) 452-0995
Mail to: Caleo Health Att’n: Spine Assessment Administrator
#200, 1402 8th Avenue N.W. Calgary, Alberta T2N 1B9
Once we have the payment your medical information will be
reviewed by one of our specialist. A staff member will contact you
in approximately 10 business days of the review to book the
appointment. At the time of your appointment we ask that you bring
any relevant diagnostic images (MRI, CT, X-RAY) on a disc and any
other spine information you may have. Your physician office may
assist you with getting your images on disc. We are unable to
retrieve your Diagnostic Disc(s) prior to seeing you. Please read
all the attached information before proceeding. Thank You! Booking
Coordinator Caleo Health | Ph: (403) 452-4798 | Fax: (403)
452-0995
Please MAIL all Documents and Payment together
If you are sending your Questionnaire by FAX send to: Caleo
Health Spine (403) 452-0995
Credit Card Payments can be made over the phone or in person:
(403) 452-4798
If you are sending your Questionnaire by E-MAIL you may call to
Join or Secure-Mail System
Riley Park Village 200 – 1402 8th Avenue N.W.
Calgary, AB T2N 1B9
Ph: 403-452-4798 Fax: 403-452-0995 http://www.caleohealth.ca
mailto:[email protected] TextSave
then e-mail to [email protected] Or Print then Mail or Fax
to Caleo Health
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SPINE ASSESSMENT REGISTRATION QUESTIONNAIRE
TO BE COMPLETED BY THE PATIENT PRIOR TO THE ASSESSMENT
(Please complete and forward to Caleo Health Spine Department,
by Email, Fax or Mail)
Patient information
First Name Last Name
Address
City Province/State Postal code
Home phone number Work phone number Extension
Cell phone number Email address
Health card number (PHN) Province issued
Please confirm your gender (sex):
Male Female
Please enter your date of birth (mm/dd/yyyy):
Are you left or right handed?
Right Left What is your weight in pounds (lbs)?
What is your height? Feet Inches
Referring Physician’s information
Name of Family Physician Office Email Address (if known)
Office Phone Number (if known) Office Fax Number (if known)
_
_
_
/ /
marklewisTypewritten TextSave then e-mail to
[email protected] Or Print then Mail or Fax to Caleo
Health
marklewisTypewritten Text
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Current Condition (History of Present Illness) Patient Name:
DOB:
Area Affected: (Select only one – the most severely affected
area)
Neck Neck with arm pain Mid Back Low Back Low Back with leg pain
Low Back/buttocks pain Cause of Symptoms/Injury:
Trauma Motor Vehicle Accident Sports Injury Work Related Injury
Fall Unknown
Describe the event:
Have you experienced this condition prior to this episode? No
Yes (if yes, when) _________________________________ Length of time
with current symptoms:
0 – 6 weeks 6 – 12 weeks 3 – 9 months 9 – 18 months > 18
months
Please Mark the area on the diagram that corresponds to where
you feel the pain. Include all affected areas: xxx = Pain
Please describe the interval of your pain/symptoms by checking
the appropriate box. Constant (pain/symptom is present all the
time) Frequent (pain/symptom is present most of the time)
Occasional (pain/symptom is present sometimes) Intermittent
(pain/symptom comes and goes)
Left Right
Left
Right
Right Left
Pain in arm(s) compared to pain in neck Worse than
Same as
Less than
Pain in leg(s) compared to pain in back Worse than
Same as
Less than
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Patient Name: How would you describe the pain/symptom(s) you
experience the most? Achy/Dull Sharp/Stabbing Numbness Burning
Stiffness Pins & Needles Other
________________________________
Please rate your current pain on a scale from 0 to 10 (0 = No
pain, 10 = Unbearable pain): __________________________ / 10 Since
the start of this condition, it is: Getting Better Getting Worse
Unchanged
What aggravates your condition? Standing ________ minutes
Walking ________ minutes Sitting ________ minutes Lifting _________
lbs
Other
__________________________________________________________________________________________________
What relieves your condition? Rest Heat Ice Exercise
__________________ Medication ________________
Other
__________________________________________________________________________________________________
Do you experience loss of control of your bowel or bladder
function: No Yes
Do you experience pain at night when sleeping? No Yes, Have you
experienced recent rapid weight loss? No Yes
Have you had surgery or procedure for this condition? No Yes (if
yes, please list the surgery/procedure(s) below)
Surgery #1 _____________________________________________
Date:_____________________ Surgeon:_________________
Surgery #2 _____________________________________________
Date:_____________________ Surgeon:_________________
Have you been hospitalised for this condition? No Yes (if yes,
which hospital) _________________________________
Previous Treatments for this Condition: (Check all treatments
previously received for this condition)
Physiotherapy Chiropractic Massage Acupuncture Naturopathic
Other ________________
Spine injections Type of injection(s): Steriod Anesthetic
(lidocaine) Trigger point Other ________________
Describe the result/reaction you had to the injection(s)/or
treatment(s):__________________________________________________
What diagnotic test(s) have you had for this condition:
X-ray MRI CT Scan Ultrasound Bone Scan Other
___________________
Do you have a copy of the images on film or CD: No Yes (if yes,
present the images to the physician at the time of the
assessment)
Medication & Allergies
Please check medications you are currently taking:
Tylenol Tylenol #3 Ibuprofen Advil Aleve Roboxacet Arthrotec
Gabapentin/Lyrica ___________mg
Tramacet/Tramadol __________mg Naproxen __________mg Morphine
__________mg Percocets __________mg Oxycontin _________mg
Enter Number here
DD / MM / YY
DD / MM / YY
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Patient Name: Please list all other medications
Allergies to medication: None Yes (if yes, please list all):
________________________________________________________
Latex Allergy Screening: Have you ever had a reaction such as;
swelling, itching or difficulty breathing when exposed to latex,
rubber materials like
gloves, condoms or balloons. No Yes (if yes, please describe
reaction): ______________________________________________
Past Medical History
Please list all medical conditions:
List all other previous surgery(s):
_______________________________________________________________________________
Please list any relavent family history:
Social & Occupational History Current Work & Activity
Status: Occupation:
____________________________________________________________________
Working On disability or leave due to condition Not working due
to condiiton
Not Working Able to do all activities despite condition
Difficulty doing activities due to condition
Social History: (Check any of the activities below that you are
currently involved with)
Do you Smoke or Chew Tobacco? No Yes if yes, how many packs per
day? _____________________________________
Do you drink alcohol? No Yes if yes, how often? ________________
x per week or _________________ x per month
Do you use any street/recreational drugs? No Yes if yes, please
specify _________________________________________
In general would you say your health is: Excellent Very Good
Good Fair Poor
Comments:
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Riley Park Village 200 – 1402 8th Avenue N.W.
Calgary, AB T2N 1B9
Ph: 403-452-0999 Fax: 403-452-0995 http://www.caleohealth.ca
SPINE ASSESSMENT INFORMATION
YOU MAY BE REFERRED TO THE CALEO HEALTH MULTIDISCIPLINARY
ASSESSMENT TEAM BY YOUR HEALTH CARE PROVIDER: PHYSICIAN,
CHIROPRACTOR OR PHYSIOTHERAPIST. YOU MAY ALSO SELF REFER TO ONE OF
OUR PHYSIOTHERAPISTS OR CHIROPRACTORS FOR SPINE ASSESSMENT &
TREATMENT. CALEO HEALTH SPINE: A partnership of Spine Surgeons
associated with the University of Calgary. The team also consists
of; Spine Focused Physicians, Physiatrists, Physiotherapist,
Chiropractors & other Allied Health Professionals. We are a
multidisciplinary patient focused centre with a structured triage
approach with emphasis on diagnostic and treatment recommendations.
The assessment process is designed to provide: single-site
management of your condition(s), coordinate investigations and
optimize care processes. We offer a continuum of care where
patients are referred to the most appropriate healthcare provider
for management and treatment. Why: To address a critical delay in
access to multidisciplinary assessment and management of patients
with spinal diseases and injuries. Caleo Health has instituted a
document review and assessment process to internally triage
referrals. What: You have been referred for assessment with our
triage team: Spine Focused Physician, Physiotherapist/Chiropractor
and rehabilitation coordinators. The assessment team will review
your file with one of our surgeons and/or they will refer you to
the appropriate specialist when deemed necessary. You will not see
a surgeon on your first visit Based on the historical assessment
and review outcomes, greater than 50% of referrals to Caleo Health
have been determined to be non-surgical. The initial visit to Caleo
Health focuses on evaluating your most critical area of complaint.
The goal is to provide you and your physician; the most responsible
diagnosis, subsequent care pathway recommendation(s) and/or the
referral(s) necessary for the treatment of your spinal condition.
As part of the assessment and management process a referral to one
(1) or more of the following may be necessary: 1. Investigational
Studies: such as, MRI, X-Ray, CT, etc. 2. Electro-diagnostics: such
as EMG or NCS studies. 3. Pain Clinic: Physiatry evaluation &
treatment (facet: injections, nerve blocks, etc.) 4. Allied Health
Professional: such as specific and specialized physiotherapy and/or
Chiropractic. 5. Medical Specialist: as deemed necessary by the
assessment team 6. Surgical Specialist: further consultation with a
surgeon to discuss surgical options. ONLY SCREENED REFERRALS DEEMED
APPROPRIATE FOR SURGICAL INTERVENTION WILL RECEIVE A FORMAL
CONSULTATION WITH A SPINE SURGEON. NON-SURGICAL PATIENTS WILL BE
PROVIDED WITH APPROPRIATE TREATMENT RECOMMENDATION(S) AND/OR
REFERRAL.
Surgeons Dr. Jacques Bouchard Dr. Roger Cho Dr. Cory Cundal Dr.
Richard Hu Dr. Paul Salo Dr. Ganesh Swamy Dr. Ken Thomas Dr. Paul
Duffy Dr. Stephan du Plessis Dr. Peter Lewkonia Dr. Dr. Deon Louw
Dr. Alex Soroceanu Orthotist Consultant Ken Moghadam Anesthetist
& Pain Management Dr. Philip Braithwaite Physiatrists &
Pain Management Dr. Tony Giantomaso Dr. Arun Gupta Dr. David
Flaschner Neurologists Dr. Scott Wilson Physicians Dr. D. Bowman
Dr. W. Meerholz Dr. M. Christie Dr. C. Morse Dr. E. Soumbasis Dr.
F. van Rooyen Dr. F. van Rooyen Dr. C. Lorincz Physiotherapists
Marco Lebrasseur Gerald Machiri Mohamud Virani Jeff Gehl Sarah Jury
Chiropractor Dr. Joanne Storring Nurses Makeda Johnson Disability
Management Amy Rost Administrative Staff Rosario Medina Danielle
Cayer Tao Jerry Wang Joy Maramara Trina Scholte Clinic Director
Marco Lebrasseur Director of Operations Dr. Mark Lewis
Neck: OffNeck with arm pain: OffMid Back: OffLow Back: OffLow
Back with leg pain: OffLow Backbuttocks pain: OffTrauma: OffMotor
Vehicle Accident: OffSports Injury: OffWork Related Injury:
OffFall: OffUnknown: OffNo: Offundefined: OffYes if yes when: 0 6
weeks: Off6 12 weeks: Off3 9 months: Off9 18 months: Off18 months:
OffWorse than: OffSame as: OffLess than: OffWorse than_2: OffSame
as_2: OffLess than_2: OffConstant painsymptom is present all the
time: OffOccasional painsymptom is present sometimes: OffFrequent
painsymptom is present most of the time: OffIntermittent
painsymptom comes and goes: OffAchyDull: OffSharpStabbing:
OffNumbness: OffBurning: OffStiffness: OffPins Needles:
Offundefined_2: OffOther: Getting Better: OffGetting Worse:
OffUnchanged: OffStanding: Walking: Sitting: What aggravates your
condition: Offminutes: Offminutes_2: Offminutes_3: OffLifting:
undefined_3: OffOther_2: Exercise: Rest: OffHeat: OffIce:
Offundefined_4: Offundefined_5: OffMedication: What relieves your
condition: OffOther_3: Do you experience loss of control of your
bowel or bladder function: OffDo you experience pain at night when
sleeping: OffHave you had surgery or procedure for this condition:
OffSurgery 1: Surgeon: Surgery 2: Surgeon_2: No_6: Offundefined_6:
OffYes if yes which hospital: Physiotherapy: OffChiropractic:
OffMassage: OffAcupuncture: OffNaturopathic: Offundefined_7:
OffOther_4: Spine injections: OffSteriod: OffAnesthetic lidocaine:
OffTrigger point: Offundefined_8: OffOther_5: Describe the
resultreaction you had to the injectionsor treatments: Xray:
OffMRI: OffCT Scan: OffUltrasound: OffBone Scan: Offundefined_9:
OffOther_6: Do you have a copy of the images on film or CD:
OffTylenol: OffTylenol 3: OffIbuprofen: OffAdvil: OffAleve:
OffRoboxacet: OffArthrotec: Offundefined_10: OffGabapentinLyrica:
TramacetTranadol: Naproxen: Morphine: Percocets: undefined_11:
Offmg: Offmg_2: Offmg_3: Offmg_4: OffOxycontin: None:
Offundefined_12: OffYes if yes please list all: gloves condoms or
balloons: Offif yes please describe reaction: List all other
previous surgerys: Current Work Activity Status Occupation:
Working: OffOn disability or leave due to condition: OffNot working
due to condiiton: OffNot Working: OffAble to do all activities
despite condition: OffDifficulty doing activities due to condition:
OffDo you Smoke or Chew Tobacco: Offif yes how many packs per day:
Do you drink alcohol: Offif yes how often: x per week or: Do you
use any streetrecreational drugs: Offif yes please specify:
Excellent: OffVery Good: OffGood: OffFair: OffPoor: OffFirst name:
Last name: Address: city: Province: [Alberta]Post code: Home: Work:
Extension: Cell: Email Address: PHN: issueing province:
[Alberta]DOB: Height Feet: Height Inches: Weight: Physician:
Physician email: Physician Office Number: Physician Fax Number:
Email this form to Spinetraige@caleohealth: caForm:
Check Box10: 0: 0: Off1: Off
1: 0: Off1: Off
2: 0: Off1: Off
4: 0: Off1: Off
5: 0: 0: 0: 0: 0: Off1: Off
1: 1: Off
1: Off101: Off
1: 1: Off102: Off
1: Off
6: 0: Off1: Off
8: 0: Off1: 0: 1: Off0: 0: 0: Off1: Off
1: 0: Off1: Off
1: 1: Off
9: 0: Off1: Off
10: 0: Off1: Off
11: 0: Off1: Off
12: 0: Off1: Off
13: 1: Off0: 0: 0: Off1: Off
1: 0: Off1: Off
14: 0: Off1: Off
15: 0: Off1: Off
16: 0: Off1: Off
17: 0: Off
18: 0: Off
19: 0: Off
20: 0: Off
21: 0: Off
22: 0: Off
23: 1: Off0: 0: 0: Off1: Off
1: 0: Off1: Off
3: 1: Off
7: 1: Off0: 1: 0: Off1: Off
0: 1: Off
Describe Event: Medical conditions: Family History: Other
Medication: Comments: Surgery date: Surgery date 2: Pain Scale:
Group12: OffSEX: OffGroup13: OffCover name: SAVE:
