WKHS Locations

Forms

If you have scheduled an appointment at The Spine Institute, you may download, print and complete the forms below to facilitate the admission process. You will need to complete the PATIENT INFORMATION AND HEALTH HISTORY form, the LOW BACK PAIN FORMS and/or the NECK PAIN FORMS, and the PAIN DIAGRAM.

You will need to arrive at The Spine Institute thirty (30) minutes before your scheduled appointment in order to complete the admission process.

Patient Information and Health History

This checklist and questionnaire relates to your current health, past medical history, past surgical history, current medications, and any testing you have had done. 

Forms coming soon

Low Back Pain Forms

These forms are to be completed if you are having complaints of Low Back Pain and/or Leg Pain.

Neck Pain Forms

These forms are to be completed if you are having complaints of Neck Pain and/or Arm Pain.

  • Neck Disability Index (pdf)
    This questionnaire has been designed to give your healthcare provider/therapist information as to how your neck pain has affected you ability to manage in every day life.
  • Neck Pain and Arm Pain Scale (pdf)
    This scale uses a number system to rate your Neck and Arm pain.


Pain Diagram

This form uses a diagram of the body and symbols to indicate what types of pain you may be experiencing and where the pain is located in relation to your body.

  • Body & Pain Diagram (pdf)
    Please mark on the drawing any areas where you feel pain. Use the symbols shown on the form to show particular types of pain.