inate pos: © 7) ColumbiaDoctors Adult New Patient Intake Form Patient Information Last Name: FirstName: Jere Re’ Gender: Home Phone: Mobile Phone: Preferred Phone: Home or Email: 4 eevacoti on Agma |. cam Emergency Contact: NA UL Relationship: Felenhy Emergency Contact Phone: Patient Marital Status: SiINGLE axe Occupation: Banke = Employer: STC- SOUTHERN TRUST CO- Primary Care Provider (PCP): Lan iqzeED HEALTHCARE PCP Phone: - - Referring Provider: De HAReY FISCH Referring Phone: Preferred Pharmacy: a Pharm Phone: Z2IZ2- (.2-¥- [110 Preferred Pharmacy Address: _J/23S5 STAVE. (@TWN Gic™2C7™) NY Please list ALL active treating physicians (i.e. pulmonologist, oncologist, internist, cardiologist, etc...) Doctor's Name: DR. Rony SHIMON _ Specialty: Doctor's Name: DR. BRUCE M4OSKOWITZ Specialty: INTERNIST Doctor's Name: Specialty: Doctor’s Name: Specialty: Collection of the following information is encouraged by federal health agencies. This information is used to monitor and improve the quality of care provided to all patients. Ethnicity: Race: o Decline Response o Decline Response o Black or African American © Hispanic or Latino 4” American-Indian or Alaska Native a Native Hawaiian or Pacific Islander Zz Not Hispanic or Latino o Asian White oO Other Preferred Language: o Decline Response Patient Financial Obligation Agreement | understand that all applicable copayments and deductibles are due at the time of service. | agree to be financially responsible and make full payment for all charges not covered by my insurance company. | authorize my insurance benefits be paid directly to ColumbiaDoctors for services rendered. | authorize representatives of ColumbiaDoctors to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. Notice of Privacy Practices: Acknowledgement of Receipt | acknowledge that | was provided with a copy of the ColumbiaDoctors Notice of Privacy Practices (NOPP). o Received © N/A (only if you received the notice from ColumbiaDoctors previously) Information Disclosure and Consent ColumbiaDoctors will provide you with the health plans that your provider(s) accepts*. If you decide to be treated by a provider who does not accept your health plan, you will be asked to sign a consent form agreeing that you accept treatment from that provider. I read and agree to all of the above (Financial Agreement, Notice of Privacy, Insurance Information). Patient or Legal Guardian Name (Print): DJeErFreey EPSTE iN Patient or Legal Guardian Signature: __ Date: Feé. | F201 e *Please refer to our website: columbiadoctors.org, for a list of insurances accepted by your provider. Version 1.8 Page 1 of 14 Updated: 6/22/2016 EFTA00313814

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— bos: © 0) ColumbiaDoctors Reason for today’s visit: General Medical Questionnaire Have you EVER had any of the following? Asthma/Breathing Problems............::se+0ee0 OY ON Heart Disease/Disorder ............ccssseseseseseens oY oN PITS sss retsinaceascerseeters - GY oN Lung Disorder.. Bleeding/Clotting Disorder. - OY oN Liver Disease Blood Pressure Disorder. - OY GN __ Neurological Disorder/Chronic Headaches. DY ON Blood Transfusion ..........ssessssssesevee " ON Psychiatric Disorder/Illness.... «OY ON ON _ Pulmonary Embolism/DVT os GY BIN EABRE FSEIEIGD sssonssesssesshisosesedsies = OY aeiN ON _ Seizure or Epilepsy . ears el» iL | DE a a cerca oY GN _ Thyroid Disorder ........ OY ON Eye Disorder (i.e. Glaucoma, cataract)........Y ON — Urinary/Kidney Disorder........c..csssssssssesseees oY oN Women Only: Gynecological Issues...........-.- oY oN Please list any other medical illnesses or problems and provide details for any of the above conditions: Please list all past surgeries and hospitalizations and the approximate date. Procedure/ Hospitalization Please indicate any major conditions/illnesses that your immediate family members have had: Condition and description If deceased, at what age? Bet) = Sn Cs CR ‘MIMO onderidd Bk BEEP RL i “Gi Cee: = | SEER Do you currently smoke? GY ON Ifno, previously? oY ON Years smoked Packs/day Do you use other tobacco products? GY GN Consumealcohol? oY ON Ifyes, drinks/week: Women Only: Any past pregnancies? o YaN How many? __ How many deliveries? Version 2.8 Page 2 of 14 Updated: 6/22/2026 EFTA00313815

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Name: please list allerq bos: Review of Systems Gh ColumbiaDoctors Do you have any allergies to medications or other substances (pets, food, etc.)? DY oN If ies and reactions (including SU) a RDA Please indicate ALL that you have experienced within the past 6 — 12 months. Constitutional OYON Fever OYON Chills Head, E) OYON Vision Problem OYON Decreased Hearing OYON Double Vision OYON Light Sensitivity OYON Itchy Eyes Cardiovascular OYON Chest Pain OYON Palpitations OYON Leg Swelling Respirat OYON Shortness of Breath OYON Cough OYON Rapid Breathing Gastrointestinal OYON Abdominal Pain OYON Blood in Stool OYON Vomiting OYON Nausea Version 2.8 OYON Fatigue OYON Feeling Poorly OYON Sweats Ears, Nose, and Throat GYON Red Eyes OYON Eye Pain OYON Runny Nose OYON Neck Stiffness OYON Nosebleed OYON Cold Extremities QYON Cold Hands or Feet OYON Leg Pain w/ Walking OYON Wheezing OYON Shortness of Breath OYON Chest Congestion OYON Diarrhea OYON Black/Tarry Stools OYON Decreased Appetite OYON Yellow Skin OYON Weight Gain (__ Lbs) OYON Weight Loss (__ Lbs) OYON Unexp. Weight Change OYON Congestion OYON Snoring OYON Dry Mouth OYON Flu-Like Symptoms OYON Sore Throat OYON Irregular Heart Rhythm OYON Other: OYON Coughing Up Blood GYON Coughing Up Sputum DO Other: OYON Change in Bowels OYON Vomiting Blood OYON Bowel Incontinence OYON Rectal Pain Page 3 of 14 OYON Sleep Disturbances © Other: OYON Hoarseness OYON Ringing in Ears OYON Vertigo OYON Earache OYON Other: o OYON Painful Swallowing O Other: Updated: 6/22/2016 EFTA00313816

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Name: OYON Constipation Neurological OYON Headache OYON Dizziness OYON Decreased Strength QYON Poor Coordination Musculoskeletal OYON Joint Pain OYON Neck Pain OYON Back Pain Genitourina YON Frequent Urination OYON Incontinence OYON Urinary Urgency OYON Painful Urination | jumenta OYON Rash OYON Dry Skin Psychiatric OYON Depression Hematol OYON Easy Bruising Endocrine OYON Excessive Thirst OYON Cold Intolerance OFFICE USE ONLY: Provider Signature: Version 1.8 DOB: ic/Lymphatic a OYON Trouble Swallowing OYON Unsteady OYON Disorientation QYON Confusion OYON Burning Sensation OYON Limb Pain OYON Joint Swelling OYON Muscle Cramps OYON Pelvic Pain OYON Nocturia OYON Itching- Genital QYON Change in Libido OYON Skin Wound GYON Change in A Mole OYON Anxiety OYON Easy Bleeding OYON Heat Intolerance OYON Changes- Hair ColumbiaDoctors OYON Heartburn OYON Numbness OYON Tingling OYON Seizures OYON Fainting (Syncope) OYON Muscle Pain OYON Muscle Weakness OYON Leg Swelling OYON Painful Intercourse OYON Discharge- Vaginal OYON Vaginal Bleeding OYON Irreg. Monthly Cycles OYON Unusual Growth OYON Itching OOther: OYON Swollen Lymph Nodes OYON Changes- Skin © Other: Page 4 of 14 OYON Tremor QYON Memory Lapses/Loss O Other: 0 Other: OYON Heavy Period Bleeding O Other: OYON Skin Cancer © Other: O Other: Date: Updated: 6/22/2016 EFTA00313817

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@2 ColumbiaDoctors | Orthopedics Additional Orthopedic Department Form Name of person completing form: rf je EEEeN ERSTE Relationship (if ni Referring provider's name: l ye. 3) Aeex } E L SCH Phone num! = Address: 14 tPAcK Nis NIY LN Y Fax number: Would you like a copy of today’s consult note sent to this doctor? ives Ono Primary care provider's name: ] 2. H2LUC EM &KOw ITZ Phone number sa West PALM BeAr Address: [Yl FLAGLER 7 00 Fax number: Would you like o copy of today’s consult note sent to this doctor? C] Yes []No 23O1 Reason for today’s visit: Which side hurts? (_] Left (] Right 1] Both How long has your reason for today’s visit been going on? How did it start? Hand dominance: O left Oo Right Pain description: [Dull [1] Sharp []Tingling [1] other: When does pain occur? (_] At rest Dlwith activity oO At night ia Other: Rate pain: (Check box) 1 2 3 4 5 6 Fi 8 9 10 Most O O O Oo O O O Oo 0 C] | eareme What reduces the pain? [(] Medicine [ice C)Heat [Rest [1] Elevation No pain Your problem has: [_] Improved [[] worsened Any other symptoms associated with the current problem? Does your home have: (Check all that apply) (]1 story []2stories [[]3+stories [Jéntrance steps [] Elevator Do you take public transportation? [] y (IN Do you exercise regularly? L]¥ []N Are you involved in organized sports? C]y [Jw Required Information: : Did this injury happen while working? (_] Yes [] No Does this injury relate to an auto accident? [] Yes [1] No Is this injury related to a pending lawsuit? [] Yes [[] No Patient Signature Date COLUMBIA UNIVERSITY + MEDICAL CENTER = NewYork-Presbyterian Page 5 of 14 Updated 3/29/17 EFTA00313818

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QW ColumbiaDoctors | Orthopedic Surgery Adult Spine Supplement Spine PLEASE USE BLUE OR BLACK INK ONLY NAME:_ J ise E REY EF STE) DATE OF BIRTH:_|—20-S3_ parte: Fen +2019 1. Chief complaint O Spinal Deformity (Scoliosis, Kyphosis, Flatback Syndrome, etc.) (check all that apply): C) Neck pain Arm: O Pain O Numbness 0 Weakness 0 Back pain Leg: O Pain OC Numbness 0] Weakness Other 2. If recommended, please rate how interested you are in having surgery to treat your problem: 0 5 10 Not at all Maybe Definitely A. +****ALL PATIENTS SHOULD ANSWER THE FOLLOWING***** Coughing or sneezing O Increases © Sometimes increases O Does not increase _ the pain. 1. 2. There is: O1 No loss of bowel or bladder control Loss of bowel or bladder control since . 3. Ihave: O Not missed any work because of this problem — () Missed (how much?) work, 4. Treatments have included: 0 No medicines, therapy, manipulations, injections, or braces Neck Back Neck Back Q OC Physical therapy, exercise Q OC Anti-inflammatory medications O OO Massage & ultrasound o Narcotic medication O OO Traction QO OQ Epidural steroid injections times which QO OC Manipulation relieved the pain for (how long)? O O. Tens Unit QO OC Trigger point injections times which Q OC Shoulder injections relieved the pain for (how long)? O O Braces O OC Other 5. Generally speaking, are your symptoms getting better or worse? (Fill in one circle) O Getting much better O Getting somewhat better O Staying about the same O Getting somewhat worse O Getting much worse 6. If you had to spend the rest of your life with the symptoms you have right now, how would you feel about it? (Fill in one circle) OVery dissatisfied | OSomewhat dissatisfied ONeutral OSomewhat satisfied OVery satisfied MY PAIN / DISCOMFORT IS: 4 2 3 4 5 6 Z 8 9 10 (circle number) I l l | l l | | No Pain Slight Mild Moderate Severe _ Exeruciating Pain as bad as it could be CONTINUED ON NEXT PAGE Page 6 of 14 EFTA00313819

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Adult Spine Supplement QW ColumbiaDoctors | Orthopedic Surgery Spine NAME: «JEFF REY) EPSTEIN) pate oF BirtH:_|-ZO-S3 pate: FEA 420!” Please fill in drawings: (shade the areas) My main goal(s) today is (are) to get (check all that apply): O) Second opinion O) Recommendation for Physical therapy O Medications C1) Injection treatments O Surgery If you have seen other surgeons for this problem and were not happy, why? QO) Didn’t answer my questions C) Had no suggestions on what to do C) Personality issues O) Office staff problems C1 Spent too little time with me O Other CONTINUED ON NEXT PAGE Page 7 of 14 EFTA00313820

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G2 ColumbiaDoctors | Orthopedic Surgery Spine NAME: JEP E REN ePereyl pate or pirtH: |-ZO-S3_pare: L-14t- IX B. we patients with NECK OR ARM problems: What % of your pain is neck pain and what % is arm pain? (check appropriate box) Adult Spine Supplement O Neck 0%, Arm 100% O Neck 10%, Arm 90% 1 Neck 25%, Arm 75% O Neck 40%, Arm 60% O Neck 50%, Arm 50% 0 Neck 60%, Arm 40% O Neck 75%, Arm 25% O Neck 90%, Arm 10% O Neck 100%, Arm 0% 2. There is: O No arm pain O Arm pain is as follows (check the following): a. O Right 0%, Left 100% Oi Right 10%, Left 90% ORight25%,Left75% O Right 40%, Left 60% O Right 50%, Left 50% 1 Right 60%, Left 40% Right 75%, Left25% O Right 90%, Left 10% O Right 100%, Left 0% b. The arm pain is present in the (check the following): Right: © Upper back O Shoulder © Upper arm O Forearm C Hand/finger Left: © Upper back O Shoulder CO Upper arm O Forearm O Hand/finger 3. Raising the arm: O Improves the pain © Worsens the pain © Does not affect the pain 4. Moving the neck: 0 Improves the pain © Worsens the pain © Does not affect the pain 5. There is: CO No weakness of the arms and hands ~~ Weakness of the (check the following): Right: Shoulder © Upper arm O Forearm O Hand/finger Left: OShoulder CO Upper arm O Forearm O Hand/finger 6. There is: C) No numbness of the arms and hands O Numbness of the (check the following): Right: O Upperarm (Forearm 0 Thumb ( Index finger 0) Long finger O Ring finger 0) Small finger Left: (Upperarm (Forearm 0 Thumb (Index finger Ol Long finger 0 Ring finger 0 Small finger 7. There( Ois Cis no) difficulty picking up small objects like coins or buttoning buttons. 8. There( Qisa Cis no) problem with balance or tripping frequently. 9. There are: ( C1 Frequent O Occasional O No) headaches in the back of the head. Patients with HEADACHES. 1. Ifyou have headaches, how would you describe their intensity and frequency? I have (check one): C0) slight Omoderate 0 severe headaches They come (check one): 0) infrequently 0 frequently © almost all the time 2. The headaches are located (check the following): a. 0 In the back of my neck _b. 0) In the back of my head c.O The side of my head/temple area d. 0 In the front of my head (near my eyes) 3. How long have you suffered from headaches? C Several days O) Several weeks O Several months 0) Greater than 1 year 4. When do the headaches occur most commonly? O Morming 0 Afternoon O While at work O Evening 0 No pattern 5. What is your average headache pain level throughout the day? (please circle) ‘1°28. 4.3.8 7 2-5 oe 6. How would you describe your pain? O Throbbing 0 Squeezing O Pressure O Dull O Stabbing 0 Shooting 7. What medications (either prescription or over-the-counter) do you take for your headaches? — CONTINUED ON NEXT PAGE Page 8 of 14 EFTA00313821

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@ ColumbiaDoctors | Orthopedic Surgery Spine Adult Spine Supplement Name: Jerpeey ERSTE) ) pos:_|-Z0- 53 DATE: Z-14-1 THE NECK DISABILITY INDEX This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage everyday activities. It is important that you answer each of the following questions. We realize that you may feel that more than one statement may relate to you, but please circle the ONE BEST ANSWER to each question which closely describes your problem right now. Pain Intensity I have no pain at the moment The pain is mild at the moment. The pain comes and goes and is moderate. The pain is moderate and does not vary much. The pain is severe but comes and goes. The pain is severe and does not vary much. Personal Care I can look after myself without causing extra pain. I can look after myself normally but it causes extra pain. 2. It is painful to look after myself and | am slow and careful, 3. Ineed some help, but manage most of my personal care. 4. I need help every day in most aspects of self-care. 5. Ido not get dressed; I wash with difficulty and stay in bed. VPeNnrFe wi Lifting 0. I can lift heavy weights without extra pain. | can lift heavy weights, but it causes extra pain. 2. Pain prevents me from lifting heavy weights off the floor but | can if they are conveniently positioned, for example on a table. 3. Pain prevents me from lifting heavy weights, but | can manage light to medium weights if they are conveniently positioned. 4. can lift very light weights. 5. I cannot lift or carry anything at all. Reading 0. [can read as much as | want to with no pain in my neck. 1. I can read as much as | want with slight pain in my neck. 2. | can read as much as | want with moderate pain in my neck, 3. | cannot read as much as | want because of moderate pain in my neck. 4. I cannot read as much as | want because of severe pain in my neck. 5. I cannot read at all. Headache 0. Ihave no headaches at all. 1. Ihave slight headaches which come infrequently. 2. Ihave moderate headaches which come in- frequently. 3. Ihave moderate headaches which come frequently. 4. Ihave severe headaches which come frequently. 5. Ihave headaches almost all the time. Concentration 0. Ican concentrate fully when | want to with no difficulty. 1. 1! can concentrate fully when | want to with slight difficulty. 2. Ihave a fair degree of difficulty in concentrating when | want to. 3. [have a lot of difficulty in concentrating when | want to, 4. | have a great deal of difficulty in concentrating when | want to. 5. I cannot concentrate at all. CONTINUED ON NEXT PAGE Page 9 of 14 EFTA00313822

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@? ColumbiaDoctors | Orthopedic Surgery Spine 0. Ian do as much work as | want to. 1. I can only do my usual work, but no more. 2. |can do most of my usual work, but no more. 3. [cannot do my usual work. 4. Ican hardly do any work at all. 5. [cannot do any work at all. Driving 0. 1 can drive my car without neck pain. 1, | can drive my car as long as | want with slight pain in my neck. 2. I can drive my car as long as | want with moderate pain in my neck. 3. [cannot drive my car as long as | want because of moderate pain in my neck. 4. can hardly drive my car at all because of severe pain in my neck. 5. [cannot drive my car at all. Office Use Only: Score L}H-1? Patient Signature and Date Adult Spine Supplement Sleeping 0. Ihave no trouble sleeping 1. Mysleep is slightly disturbed (less than 1 hour sleepless). My sleep is mildly disturbed (1-2 hours sleepless). 3. My sleep is moderately disturbed (2-3 hours sleepless). My sleep is greatly disturbed (3-5 hours sleepless). 5. Mysleep is completely disturbed (5-7 hours sleepless). Recreation Lad > 0. 1am able engage in all recreational activities with no pain in my neck at all. 1. 1am able engage in all recreational activities with some pain in my neck. 2. lam able engage in most, but not all recreational activities because of pain in my neck. 3. lam able engage in a few of my usual recreational activities because of pain in my neck. 4. | can hardly do any recreational activities because of pain in my neck. 5. | cannot do any recreational activities at all Physician Signature and Date CONTINUED ON NEXT PAGE Page 10 of 14 EFTA00313823

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G2 ColumbiaDoctors | Orthopedic Surgery rn ~ Adult Spine Supplement name’ Jere Rey ERSTEIN) pate or sintn: |-20-S3 pare: Z-)4- ee C. For patients with BACK OR LEG Problems: DON*T DO IF BEING SEEN FOR A NECK PROBLEM 1. What % of your pain is back pain and what % is leg or buttock pain? (check appropriate box): 0) Back 0%, Leg 100% O Back 10%, Leg 90% 0 Back 25%, Leg 75% O Back 40%, Leg 60% 0 Back 50%, Leg 50% O Back 60%, Leg 40% O Back 75%, Leg 25% 0 Back 90%, Leg 10% C1 Back 100%, Leg 0% 2. There is: © No leg pain C Leg pain as follows (check the following): a. DO Right 0%, Left 100% Right 10%, Left90% O Right25%,Left75% O Right 40%, Left 60% O Right 50%, Left 50% Right 60%,Left40% O Right 75%, Left 25% ( Right 90%, Left 10% 0 Right 100%, Left 0% b. The pain is present in the (check the following): Right: Buttock © OThigh-front CI Thigh-back O Calf Ci Foot Left: 0 Buttock O Thigh-front O Thigh-back 0 Calf 0 Foot 3. There is: O No weakness of the legs 0 Weakness of the (check the following): Right: © Thigh Ocalf Ankle OFoot OBigtoe Left: O Thigh O Calf O Ankle OFoot OBigtoe 4. There is: 1 No numbness of the legs CI Numbness of the (check the following): Right: 0 Thigh O Calf 0) Foot Left: O Thigh OCalf O Foot 5. The worst position for the pain is: O Sitting C Standing O Walking 6. How many minutes can you stand in one place without pain? 0-10 0 15-30 030-60 60+ 7. How many minutes can you walk without pain? O0-10 015-30 030-60 060+ 8. Lying down: O Eases the pain C Does not ease the pain 1 Sometimes eases the pain 9. Bending forward: Cl Increases the pain Decreases the pain 0) Doesn’t affect the pain In the past week, how often have you suffered: (Please circle the number that applies) etme | ete | actin | arte | arte || the time | the time | of the time | the time | the time 10. Low back and/or buttock pain.................. 1 2 3 4 5 6 Wis TA BRI 6 one rs sceasnansa=n0i<eereensaysanancing 1 2 3 - 5 6 12. Numbness or tingling in leg and/or foot...... 1 2 3 4 5 6 13. Weakness in leg and/or foot (such as difficulty LURES ED inca coe civbvatasenaps cei gnathcaeiet 1 2 2 4 5 6 In the past week, how bothersome have these symptoms been? (Please circle the number that applies) Not at all Slightly Somewhat | Moderately Very Extremely bothersome | bothersome | bothersome | bothersome | bothersome | bothersome S 4 5 6 14. Low back and/or buttock pain............ 1 v2 RS ae ee wee 1 2 a 4 5 6 16. Numbness or tingling in leg and/or foot... 1 2 3 4 5 6 17. Weakness in leg and/or foot (such as difficulty lifting foot)................00000 1 2 3 a ~ 6 CONTINUED ON NEXT PAGE Page 11 of 14 EFTA00313824

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@2 ColumbiaDoctors | Orthopedic Surgery Adult Spine Supplement Spine For patients with a SPINAL DEFORMITY/ BACK CURVATURE. 1. How was your spinal deformity discovered? 2. Do you know your present curve measurement(s)? 3. Reason(s) for seeking treatment at this time: DO progressive deformity pain © can’t stand straight O I don’t like the appearance of my back/waistline © Other: CONTINUED ON NEXT PAGE Page 12 of 14 EFTA00313825

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QW ColumbiaDoctors | Orthopedic Surgery Spine Adult Spine Supplement name: JEFFREY CPSTE)) pos:_|-Z0-S3 DATE: Z-14-1f THE BACK DISABILITY INDEX This questionnaire is designed to enable us to understand how much your back pain has affected your ability to manage everyday activities. It is important that you answer each of the following questions. We realize that you may feel that more than one statement may relate to you, but please circle the ONE BEST ANSWER to each question which closely describes your problem right now. Pain Intensity 0. | can tolerate the pain | have without having to use pain killers. 1. The pain is bad but | manage without taking pain killers. 2. Pain killers give complete relief from pain. 3. Pain killers give moderate relief from pain. 4. Pain killers give very little relief from pain. 5. Pain killers have no effect on the pain, | do not use them. Personal Care (Washing, Dressing, etc.) 0. I can look after myself normally without it causing extra pain. 1. | can look after myself normally but it causes extra pain. 2. It is painful to look after myself and | am slow and careful. 3. Ineed some help but manage most of my personal care. 4. Ineed help every day in most aspects of self-care. 5. Ido not get dressed, wash with difficulty and stay in bed Lifting 0. I can lift heavy weights without extra pain. 1. I can lift heavy weights but it gives extra pain. 2. Pain prevents me from lifting heavy weights off the floor, but | can manage if they are conveniently positioned. (e.g., on a table.) 3. Pain prevents me from lifting heavy weights, but | can manage light to medium weights if they are conveniently positioned. 4. I can lift only very light weights. 5. I cannot lift or carry anything at all. Page 13 of 14 Walking PrP Pain does not prevent me from walking any distance. Pain prevents me walking more than 1 mile. Pain prevents me walking more than 1/2 mile. Pain prevents me walking more than 1/4 mile. | can only walk using a stick or crutches. | am in bed most of the time and have to crawl to the toilet. Sitting yreo I can sit in any chair as long as | like. | can only sit in my favorite chair as long as | like. Pain prevents me from sitting more than one hour. Pain prevents me from sitting more than thirty minutes. Pain prevents me from sitting more than ten minutes. Pain prevents me from sitting at all. Standing 0. 1. 2 I can stand as long as | want without extra pain. I can stand as long as | want but it gives extra pain. Pain prevents me from standing more than one hour. Pain prevents me from standing more than thirty minutes. Pain prevents me from standing more than ten minutes. Pain prevents me from standing at all. CONTINUED ON NEXT PAGE EFTA00313826

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QW ColumbiaDoctors | Orthopedic Surgery Anarene Spine Sleeping Social Life 0. Pain does not prevent me from sleeping well. 0. My social life is normal and gives me no extra pain. 1. I can sleep well only by using tablets. 1. My social life is normal but increases the degree of 2. Even when | take tablets | have less than six hours pain. sleep. 2. Pain has no significant effect on my social life apart 3. Even when | take tablets | have less than four hours from limiting my more energetic interests, (e.g., sleep. dancing, etc.). 4. Even when | take tablets | have less than two hours 3. Pain has restricted my social life and | do not go out sleep. as often. 5. Pain prevents me from sleeping at all. 4. Pain has restricted my social life to home. 5. Ihave no social life because of pain. Employment/Homemaking Traveli 0. My normal homemaking/job activities do not cause pain. 0. I can travel anywhere without extra pain. 1. Mynormal homemaking/job activities increase my 1. I can travel anywhere but it gives extra pain. pain, but | can still perform all that is required of 2. Pain is bad but | manage journeys over two hours. me. 3. Pain restricts me to journeys less than one hour. 2. 1! can perform most of my homemaking/job duties, 4. Pain restricts me to short journeys under thirty but pain prevents me from performing more minutes. physically stressful activities. (e.g. lifting, 5. Pain prevents me from traveling except to the vacuuming). doctor or hospital. 3. Pain prevents me from doing anything but light duties. 4. Pain prevents me from doing even light duties. 5. Pain prevents me from performing any job or homemaking chores Office Use Only: Score Z-)4- 19 Patient Signature and Date Physician Signature and Date Page 14 of 14 EFTA00313827