Vertebroplasty Contact Information

If you feel that vertebroplasty may benefit you, please complete the attached checklist and send the requested materials to the listed address. Please note that we cannot evaluate a patient without the x-rays or the completed survey. In some cases, additional x-rays may be necessary.

Checklist:

  1. Gather all imaging of the spine that have been completed so far. These may include x-rays, MRI, CT, and bone scan.
  2. Please print and complete both pages of the vertebroplasty questionnaire including pain diagram.
  3. Send all images and completed survey materials to the following address:

Ms. Linda Donoff, Patient Coordinator
Department of Radiology
Room A121 Emory University Hospital
Atlanta, GA 30322
(404) 712-4991

We look forward to hearing from you. After reviewing the films and questionairre, we will contact you with the results of our evaluation and possibly schedule an appointment for consultation with an Emory physician.

Vertebroplasty Candidate Questionnaire - Date: __________

Name: _____________________________________________

Date of Birth: ________________________________________

Address: ___________________________________________

__________________________________________________

Phone: ___________________________________________

Social Security Number: _____________________________

Please List All Medications:

Pain Survey:

1. Duration of Pain: _____ Months

2. Severity of Pain: 1 2 3 4 5 6 7 8 9 10 (circle one)

3. Location of Pain: Please draw location of pain in diagram below.

Pain Diagram Vertebroplasty | Emory Radiology

Medical History: Are you on blood thinners (eg. Coumadin)? ___ Yes ___ No

Is a physician treating your osteoporosis? ___ Yes ___ No

 Are you taking steroid medications (eg. Prednisone, Dexamethasone)? ___ Yes ___ No

Do you have any of the following medical conditions? (circle all that apply)

Diabetes Heart Disease Liver Disease
Lung Disease High Blood Pressure Organ Transplant
     

Please send any spine x-rays and this questionairre to:

Ms. Linda Donoff, Patient Coordinator
Department of Radiology, Room A121
Emory University Hospital
1364 Clifton Road, NE
Atlanta, GA 30322

Learn more about Vertebroplasty

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