P.O. Box , San Diego, CA Phone Fax INITIAL EVALUATION
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1 INITIAL EVALUATION 1. Referring Physician: 2. Patient ID # 3. Your appointment is with Dr. Christopher Chisholm Dr. Timothy Chong PATIENT INFORMATION 4. Last Name First M.I Appointment Date 7. Date of Birth (mm/dd/yyyy): 8. Age 9. Primary Care Physician (if not the same): ABOUT YOUR PAIN 10. What is the main problem for which you are seeking treatment with Comprehensive Pain Management Specialists? Please mark the area(s) in which your pain is located: For office use only: C: C/PT: C/TDD: Page 1 of 7
2 ONSET OF PAIN AND DURATION 11. Briefly describe when and how your current pain started? TIMING OF PAIN 12. How often do you have your pain (please check one)? (100% of the time) Frequently (75% of the time) (50% of the time) (25% of the time) PAIN QUALITY 13. How would you describe the pain (choose as many adjectives as are applicable)? -like PAIN INTENSITY 14. Circle your current pain intensity with 0 representing no pain and 10 representing the most severe pain imaginable: 15. Circle your average pain the last 7 days: 16. Circle your best pain score the last 7 days: 17. Circle your worst pain score the last 7 days: Page 2 of 7
3 RELIEVING AND AGGRAVATING FACTORS How do the following affect your pain (please check one for each item)? Decrease Increase No Change Lying down Standing Sitting Walking Exercise (if applicable) Medications Relaxation Thinking about something else Coughing/Sneezing Urination Bowel movements PAIN TREATMENTS Please check all of the treatments you have tried for your pain and then complete the appropriate column at the right to the best of your ability Date Excellent Moderate No Treatment (approx.) Relief Relief Relief Hospital bed rest Traction Surgery Hypnosis Acupuncture Nerve block/injections TENS Physical therapy Exercise Heat treatment Biofeedback Psychotherapy Chiropractic Other FUNCTIONAL LIMITATIONS 24. During the past month, place a check mark next to the activities that you avoided because of pain: ing Page 3 of 7
4 25. How many blocks can you walk before having to stop due to pain? 26. How many minutes or hours can you sit before having to get up and move about? minutes hours 27. How many minutes or hours can you stand before you have to sit down? minutes hours 28. How often during the day do you lie down because of pain? Allergies 29. Do you have symptoms like red itchy eyes, general itching, shortness of breath, wheezing, fast heartbeat, feeling faint, nausea, or vomiting when exposed to the following? Dye Iodine Medications: Describe: Shellfish Foods: Latex Rubber (Band-aids, tape, spandex, balloons) * Kiwis, chestnuts, bananas, avocado * No Known Allergy After doctor/dental visits * MEDICATIONS 30. Please list your current medications with dosages: 31. Please list any previously taken pain medications that you stopped taking and the reason for stopping: Page 4 of 7
5 PAST MEDICAL HISTORY 32. Have you had any of the following health problems (please check all that apply)? y disease Please explain any medical conditions checked above: (please specify): ALL PAST SURGERIES 33. Please list, with approximate date and type of operation: Have you had any previous back surgeries (please specify)? PSYCHOSOCIAL HISTORY 34. Your highest educational level achieved: or trade-technical school graduate LEGAL ISSUES 35. Have you filed any legal claims related to your pain problem? PSYCHOLOGICAL TREATMENT 36. Have you ever had psychiatric, psychological, or social work evaluations or treatments for If yes, when? 37. Have you ever considered suicide SUBSTANCE USE 38. Y 39. N Are you suffering from or do you have a history or alcoholism? Any illicit drug use? Have you ever been in a detoxification program for drug abuse? Alcoholics Anonymous? Narcotics Anonymous? Page 5 of 7
6 40. Do you or did you ever smoke cigarettes or use tobacco? How many years have you smoked/did you smoke? How many packs per day do you/did you smoke? Have you quit using tobacco, and if so how long ago? 41. How many drinks of each of the following do you consume in one week? Beer Wine Liquor FAMILY LIFE 42. I currently am : Living with friends 43. N 44.Y Do you have members of your family who have committed suicide? Do you have members of your family who have had psychiatric illnesses? Have any of your blood relatives had substance abuse problems, including alcohol? PREVIOUS DIAGNOSTIC STUDIES 45. Please indicate approximate date and results, if known: MRI CT X-rays EMG Page 6 of 7
7 REVIEW OF SYSTEMS Fill out and/or check all that apply to your health: Do you have a history of passing out with needles, medical procedures etc.? If yes, please explain. Positives 46. Negatives 47. Page 7 of 7
PAIN INFORMATION SHEET
PAIN INFORMATION SHEET PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE SENSATIONS DESCRIBED BELOW. PLEASE USE THE APPROPRIATE SYMBOL & INCLUDE ALL AREAS. **** ==== OOOO XXXX //// ACHE **** NUMBNESS
INFORMATION SHEET FOR THE DEPARTMENT OF PAIN AND PALLIATIVE CARE
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NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD
Name: Height: Birthdate: Weight: Chief Complaint: What is the reason for your appointment? (please describe why you are here) Medications: Please list ALL medications with dosages you are currently taking,
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form
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INITIAL PAIN EVALUTION QUESTIONNAIRE
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HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions
Initial Pain Questionnaire
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COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name
PATIENT HEALTH HISTORY
Southern Oregon Physical Therapy Associates, Inc. 924 S. Riverside Ave. Medford OR 97501 541.773.7678 Fax 541.773.5517 Email: sopta@integra.net website: southernoregonphysicaltherapy.com Health History-1
New Patient Pain Evaluation
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Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
New Patient Pain History Form
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Orthopedic Care Specialists Spine Center
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SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell
PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:
Patient Name: Patient Date of Birth: Appointment Date: Please mark and/or notate the areas of your body which are affected by pain. RIGHT RIGHT LEFT LEFT RIGHT LEFT RIGHT RIGHT LEFT LEFT RIGHT LEFT For
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Please indicate where your present pain level is by circling the number that best describes the intensity: No Pain Mild Moderate Severe
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GUPTA SPORTS & SPINE CENTER
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Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE
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Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
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CERVICAL Orthopedic Specialists of Louisiana Pierce D. Nunley, MD PERSONAL INFORMATION. Patient Name:
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Aspire Pain Medical Center
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reasons for visit factors of complaint Date: Work comp injury Automobile accident Other injury
Date: LAST NAME FIRST NAME DATE OF BIRTH CURRENT AGE PRIMARY CARE PHYSICIAN PHONE NUMBER REFERRING PHYSICIAN PHONE NUMBER reasons for visit Work comp injury Automobile accident Other injury PRIMARY REASON
Name Date Date of Birth. Age Sex: M F Height: ft. in. Weight lbs. Primary Physician Referring Physician (If Different) When did the pain begin?
(Please fill out this form and bring it with you to your appointment.) Name of Birth Age Sex: M F Height: ft. in. Weight lbs Primary Physician Referring Physician (If Different) CURRENT PROBLEM Please
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
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WORKER S COMPENSATION PAIN QUESTIONNAIRE
Patient Name: Patient Date of Birth: Appointment Date: Please mark and/or notate the areas of your body which are affected by pain. RIGHT RIGHT LEFT LEFT RIGHT LEFT RIGHT RIGHT LEFT LEFT RIGHT LEFT For
Pacific Coast Medical Group, PLLC dba Bellevue Pain Institute NE 8th St. Ste. 200 Bellevue, WA
PATIENT INFORMATION PHONE NUMBERS Date: Sex: M F Home: Work: Name: Address: City: State: Zip: Single Married Widowed Separated Divorced Cell: AT&T Verz T-Mob Nextel Virgin Sprint Email: Best time to reach
Pain Drawing. Name: Today s Date: How were you referred to the office: Visual Analog Scale
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Subjective Medical History Information
Page 1 of 8 Date: Patient Account #: Patient Name: Insurance: Date of Birth: History of current condition 1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical
PATIENT INTAKE FORM. Name Date of Birth Age. Address Sex. Home Phone Primary Care Physician. Address Phone # Referring Physician.
PATIENT INTAKE FORM Date Name Date of Birth Age Address Sex Home Phone Primary Care Physician Address Phone # Referring Physician Address Phone # CHIEF COMPLAINT: Describe in your own words why you came
LUMBAR Orthopedic Specialists of Louisiana Pierce D. Nunley, MD PERSONAL INFORMATION. Patient Name:
PERSONAL INFORMATION (Please Print or Type) Patient Name: Last First MI Registration Date: / / Birthdate: / / Age: Social Security #: - - Sex: Address: Apt. # Street Telephone Numbers: ( ) Occupation:
**PLEASE NOTE OUR NEW ADDRESS** The Spine Center 159 Wells Ave, Newton, MA Ph: Fax:
Helpful Telephone Numbers Pre-Registration 855-890-9241 Hospital Billing (NWH) 617-726-3884 Physician/Provider Billing (MGPO) 617-726-3884 Web Address nwh.org Pre-Registration Please call up to 7 days
Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State
Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married
Date: Chart # DC # Spouse / Parent / Legal Guardian Details: Name: Relation:
Leader Heights Spine, Joint & Nerve Associates Date: Chart # DC # Patient Information: Please print clearly and complete all sections. Please Circle : Mr. Mrs. Ms. Miss Dr. Rev. Marital Status : Single
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.
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University of Maryland Medical Center Initial Employee Health Evaluation
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PATIENT REGISTRATION FORM
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Dr. Hall New Patient Paperwork Please fill out these forms completely
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CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:
JOSE G. VELIZ MD, INC. Diplomate of the American Board of Interventional Pain Management Diplomate of the American Board of Anesthesiology Diplomate of the American Board of Pain Medicine Fellow of Interventional
GENERAL INFORMATION PROFESSIONAL REFERRAL INFORMATION
SO THAT WE MAY BETTER SERVE YOU, PLEASE COMPLETE THE FOLLOWING FORM AND EITHER BRING THE COMPLETED FORM WITH YOU TO YOUR FIRST APPOINTEMNT OR SCAN IT AND EMAIL IT TO OFFICE, PRIOR TO YOUR APPOINTMENT LORRAINE@ANALIPSONMD.COM
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IMAGING POLICY. Please contact the facility where imaging was performed for information on how to obtain disk(s).
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