Patient Questionnaire | Dr. Erik Gerlach — Indianapolis Spine Surgeon

New patient questionnaire

Let’s get ready for your visit with Dr. Gerlach

Whether you were referred or are coming on your own, these questions help Dr. Gerlach understand your spine condition before you arrive. It takes about 5–7 minutes.

Please answer as accurately as you can. There are no wrong answers — this simply helps the care team prepare. A few questions check for symptoms that occasionally need urgent attention.

About you

Your information

So we can match this to your appointment or referral and reach you.

First name Last name Date of birth Best phone Referring doctor (if any) Insurance plan

Your concern

Where is your main problem?

Pick the area that bothers you the most right now.

Lower backLow back, buttock, or pain/numbness going down a leg NeckNeck, shoulder, or pain/numbness going down an arm Mid-backBetween the shoulder blades / mid-spine

A few important checks

Have you noticed any of these?

Check every one that applies to you. Leave blank any that don’t. Most people check none.

Recently or currently

Check all that apply

New trouble controlling your bladder or bowelsLoss of control, or being unable to go New numbness around the groin, inner thighs, or buttocksThe area that would touch a saddle New or worsening weakness in both legs Weakness that is clearly getting worseA foot, hand, arm, or leg becoming weaker New problems with balance, walking, or clumsy handsTrouble with buttons, handwriting, or unsteady gait A significant fall or accident caused this Fevers, chills, or severe pain that wakes you at night A history of cancer, or unexplained weight loss

Daily life

How your spine affects everyday activities

For each group, choose the one statement that best describes you today.

Thank you — you’re all set

Dr. Gerlach’s team has received your answers and will review them before your visit. The office will call you to schedule.

Questions before then? Call the office at (317) 893-1250, Monday–Friday, 8 AM–5 PM.

If your symptoms get noticeably worse before your appointment — especially new weakness, or loss of bladder or bowel control — call 911 or go to the nearest emergency department. For other questions, call the office at (317) 893-1250.

Your pre-visit spine questionnaire.