Name: 03-07-05 Circle Your Best Answer
Have you been diagnosed with a compression fracture?
Which region or regions of the spine is your fracture(s) in?
When did your fracture(s) occur? Approximate date: __________________________________
Do you have pain associated with this fracture(s)?
If you have more than one fracture, which region(s) of the spine is painful?
Does the pain travel into your arms, thighs (above knees), legs (below knees)?
Do you have numbness and/or tingling in your arms, thighs, legs, and/or groin?
Do you use a cane or walker, to assist you?
Please circle all treatments you have received for your current spine pain.
Have you ever had steroid injections in your spine for this problem?
If yes, what type of relief did the injection give?
Complete relief Pain worse after injection
Please indicate what type, when and where your most recent imaging studies were taken:.
Please list all painmedications you have taken for your spine pain in the past two weeks.
Please list all other medications you are taking (use back of page for additional medicines)
Are you taking Aspirin or other blood thinners? : Yes
If yes, how long have you taken oral steroids?___________________________
Have you had the diagnosis of osteoporosis prior to this fracture?
If Yes, when were you diagnosed with osteoporosis?______________________________
If Yes, what treatment have you received for osteoporosis? Circle all those that apply:
Pain medication injections Actonel, Calcitonin (Calcimar, Miacalcin)
Evista, Forteo, Fosamax (If Yes, how long have you taken Fosamax?
What was your height at age 25? ________________________
For women only, how old were you when you started menopause?_________________
Do you have any allergies to medication?
If yes, please list allergies:_______________________________________________
Have you ever had an allergic reaction to contrast material (x-ray dye), iodine, or shellfish?
If yes, please list what type of cancer: ____________________________________
Please check all other medical problems you have.
Medical History: Check all: Is your primary doctor aware of the above checked problems?
If you have had spine surgery, please describe which region of the spine was involved and why surgery was
Review of Systems: Check all. Women Only: 03-07-05 Please shade your areas of pain in the diagram below.
Sewer Use Guideline 1.0 INTRODUCTION These guidelines have been prepared to assist staff and students in determining whether certain liquid wastes may be discharged into drain systems on University premises. The University's Environmental Policy (No. 72) and the Environmental Management Policy (No. 91) require us to comply with all applicable laws, regulations, codes, by-laws and
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