Santo Steven BiFulco, M.D. CLCP

Life Care Plans

Orthopedic, Neurological & Musculoskeletal Rehabilitation Consultations
228 East Bearss Avenue, Tampa, Florida 33613 Phone: (813)321-3676 │Fax: 813-413-2980

Patient Questionnaire Form

Background- Personal
Subjective Medical Reporting

Do you experience difficulty with any of the following? If so, please explain.

List your current Medications
List each surgery you have had after the incident
If you are scheduled for any surgeries, please list. Also, include recommended surgeries
Select each type of treatment you have received since the incident
During the incident did you...
Strike your head?
Lose Consciousness?
If you are experiencing pain, please identify the affected body part(s) and rate your pain intensity using a 0-10 scale. (0 indicates no pain, 10 indicates worst pain possible.)
Please list any doctors providing treatment for conditions associated with the incident.
Please select any problems with mental functioning you have experienced since the incident.
Please indicate if you have had any of the following.
Activities of Daily Living(ADL)

Rate your current ability to perform the following physical activities during an 8-hour day. If you are an unemployed, fill out an estimate of your ability to perform these tasks.

Can't do it for any length of time
up to 33%(0-2.3 hrs/day)
From 34% to 66%(2.3-5.5 hrs/day)
More than 67% of the time(5.5+ hrs/day)
{{adl | capitalize}}
Please indicate the extent to which the mental health issues listed concern you:
Not at all
Somewhat Moderately Very Much
{{mhi | capitalize}}