INITIAL PAIN QUESTIONNAIRE

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4 INITIAL PAIN QUESTIONNAIRE 501 Cetronia Road, Suite 125 Allentown, PA Ostrum Street Bethlehem, PA Parkinsons Road East Stroudsburg, PA St. Luke s Boulevard, Suite 200 Easton, PA Memorial Parkway, Suite 201 Phillipsburg, NJ Pine Street Tamaqua, PA Park Avenue, Suite 310 Quakertown, PA Phone: (484) Fax: (484) Date: Date of First Visit: Please complete this form prior to your first visit to the Spine and Pain Center. Name: Age: Date of birth: Referring Physician: Primary Care Physician: What is the main problem for which you are seeking treatment? How long have you had this current pain problem? Years Months Please check: Are you Right Handed Left Handed How did your current pain start? Injury at work Injury not at work Motor vehicle accident Illness, non-injury Treatment caused (e.g. radiation, surgery, etc.) Undetermined Other (please describe): Date of accident: In general, over the past month, the intensity of pain has been: Mild Moderate Moderate Severe Severe With 10 being the most severe, rate your pain from 0 10 With 10 meaning your pain greatly interferes with your activities of daily living and 0 meaning the pain does not interfere with activities of daily living, rate your pain from 0 10 How often do you have pain? (Check one) Constantly (100% of the time) Nearly constantly (60 95% of the time) Intermittently (30 60% of the time) Occasionally (less than 30% of the time) In general, during the past month, when has your pain been the worst: (Please check one) Morning Afternoon Evening Night No typical pattern Form No NP Page 1 of 7 Rev. 08/16

5 Please describe your pain: (Check all that apply) Burning Sharp Pressure-like Cramping Dull/Aching Throbbing Shooting Cutting Other (describe): Numbness Pins and Needles Have you had weakness in your: Upper extremities Dropping objects Lower extremities Other (describe): Pain Location: Please mark the location(s) of your pain on the diagrams with an X. If entire areas are painful, please shade in these areas. FRONT BACK How do the following affect your pain? (Please check one for each item.) DECREASE NO CHANGE INCREASE Prayer Lying down Standing Bending Sitting Walking Exercise Relaxation Coughing/Sneezing Bowel movements Menstruation Form No NP Page 2 of 7 Rev. 08/16

6 Do you use a: Cane Walker Wheelchair No assistance device Please list the names of the physicians you have seen for this pain problem and the year: Year: Year: Year: Year: List all studies you have had for this problem: (X-rays, MRIs, CT Scans, Blood Tests, Myelograms) Study: Facility where taken: Year: Study: Facility where taken: Year: Study: Facility where taken: Year: Study: Facility where taken: Year: PAIN TREATMENTS: (Please check your response to all the treatments you have tried.) TREATMENT NO RELIEF MODERATE RELIEF EXCELLENT RELIEF Surgery Traction Nerve block/injection Physical Therapy Exercise TENS Heat/Ice Treatment Psychotherapy Acupuncture Hypnosis Biofeedback Chiropractic Manipulation Osteopathic Manipulation Form No NP Page 3 of 7 Rev. 08/16

7 PAIN MEDICATIONS: (Please check all medications you have used for treatment of pain.) Opioids Current Past NSAIDs/Tylenol Current Past Muscle Relaxants Current Past Codeine Acetaminophen (Tylenol ) Alprazolam (Xanax ) Demerol Aspirin Baclofen Fentanyl (Duragesic ) Celebrex Carisoprodol (Soma ) Hydrocodone (Vicodin ) Ibuprofen (Advil/Motrin ) Cyclobenzaprine (Flexeril ) Hydromorphone (Dilaudid ) Indocin Diazepam (Valium ) Methadone Lodine Lorazepam (Ativan ) Morphine (MSContin ) Meloxicam (Mobic ) Metaxalone (Skelaxin ) Oxycodone (Percocet ) Nabumetone (Relafen ) Parafon Forte Oxycontin Naproxen Robaxin Oxymorphone (Opana ) Oxaprozin (Daypro ) Tizanidine (Zanaflex ) Propoxyphene (Darvocet ) Piroxicam (Feldene ) Tapentadol (Nucynta ) Salsalate/Trilisate Tramadol (Ultram ) Toradol OTHER Current Past OTHER Current Past TOPICALS Current Past Amitryptilline (Elavil ) Carbamazepine (Tegretol ) Capsaicin Duloxetine (Cymbalta ) Depakote Diclofenac (Flector ) Nortriptyline (Pamelor ) Dilantin Lidocaine patch (Lidoderm ) Oral Steroids (eg: Prednisone ) Gabapentin (Neurontin ) Pennsaid Paroxetine (Paxil ) Imitrex Voltaren Gel Sertraline (Zoloft ) Klonopin Qutenza Suboxone (Buprenorphine ) Lyrica (Pregablin ) Venlafaxine (Effexor ) Savella Topiramate (Topamax ) PAST MEDICAL HISTORY: Have you had any of the following? (Please check all that apply) Alcoholism Depression High Cholesterol Stomach Ulcers Anxiety Diabetes Hypertension Stroke Asthma or Wheezing Emphysema Kidney Disease Thyroid Disease Bleeding Problem Fibromyalgia Liver Disease Chest Pain or Angina GERD/Reflux Psychiatric Problems Coronary Artery Disease Heart Attack Seizure or Epilepsy Name of Psychiatrist/ Therapist: Arthritis (specify location): Cancer (specify type): Other (specify): Form No NP Page 4 of 7 Rev. 08/16

8 PAST SURGICAL HISTORY: List all surgeries you have had in the past and approximate date. Date Type of Surgery/Procedure ALLERGIES TO MEDICATIONS: List the names of all medications to which you are allergic. Medication Type of Reaction NO known drug allergies. Are you allergic to contrast dye used for x-rays? YES NO Are you allergic to latex? YES NO CURRENT MEDICATIONS YOU TAKE FOR PAIN: Name Dose Frequency Are these pain medications providing relief? None of the time Some of the time Most of the time All of the time Form No NP Page 5 of 7 Rev. 08/16

9 ALL OTHER CURRENT MEDICATIONS (OTHER THAN PAIN MEDICATION): Name Dose Frequency SOCIAL HISTORY: Employed full time Employers Name: Phone: Employed part time Current occupation: Unemployed Retired Student Homemaker Are you unemployed or employed part time due to your present pain condition? YES NO PLEASE COMPLETE ALL QUESTIONS Do you smoke? YES NO Do you drink alcohol? YES NO Beer Wine Liquor How much nicotine per day? How many glasses per week? Do you use marijuana? Other recreational drugs? Marital Status: Married Single Widowed Divorced Separated Do you live alone? YES NO Who do you live with? Are you pregnant? NO YES N/A LEGAL ISSUES: Please indicate any of the following claims you have filed related to your pain problem. Workers Compensation Social Security Disability Insurance Personal Injury/Liability Other Insurance FAMILY HISTORY: Do you have a family history of the following? Back Disorder YES NO Heart disease YES NO High Blood Pressure YES NO Diabetes YES NO Stroke YES NO Thyroid Disease YES NO Neuropathy YES NO Cancer YES NO Other: If Yes, type of cancer Form No NP Page 6 of 7 Rev. 08/16

10 Living (age) Deceased (age) Cause of death Father Mother Brothers Sisters REVIEW OF SYSTEMS: Please check all symptoms that you have now or have recently had. Recent weight loss Wheezing Recent weight gain Memory loss Fever Loss of consciousness Dizziness Seizures Difficulty swallowing Easy bruising Difficulty walking Easy bleeding Double or blurry vision Rash Muscle weakness Frequent Urination Nausea Excessive thirst Vomiting Adrenal disease Constipation Hypothyroidism Diarrhea Hyperthyroidism Difficulty initiating urine stream Joint stiffness Genital pain Decreased range of motion Chest pain Depression Heart palpitations Swelling (specify): Shortness of breath Pain in extremity (specify): PLEASE NOTE THAT WE DO NOT DETERMINE DISABILITY. IT IS YOUR RESPONSIBILITY TO NOTIFY OUR OFFICE 48 HOURS PRIOR TO MEDICATION REFILL. Patient Signature: Date: Time: All other review of systems negative ROS and PFSH reviewed by: Date: Time: SIGNATURE OF PHYSICIAN Updated: Date: Time: SIGNATURE OF PHYSICIAN Form No NP Page 7 of 7 Rev. 08/16

11 OSWESTRY DISABILITY INDEX Name: Ase: Date: Raw Score: Please complete this questionnaire by circling gllganswer in each section. It is designed to give us inforrnation as to how your back (or leg) trouble has affected your ability to manage in everyday life. SECTION 1 - Pain Intensity A. I have no pain at the moment. B. The pain is very mild at the moment. C. The pain is moderate at the moment. D. The pain is fairly severe at the moment. E. The pain is very severe at the moment. F. The pain is the worst imaginable at the moment. SECTION 2 - Personal Care A, I can look after myself normally without causing extra pain. B. I can look after myself normally but it is painful. C. It is painful to look after myself and I am slow and careful. D. I need some help but manage most of my personal care. E. I need help every day in most aspects of self care. F. I do not set dressed. wash with difficulty and stay in bed. SECTION 3 - Lifting A. I can lift heavy weights without extra pain, B. I can lift heavy weights but it gives extra pain C, Pain prevents me from lifting heavy weights offthe floor but I can manage if they are conveniently positioned, e.g., on a table. D. Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. E. I can lift only very light weights. F. I cannot lift or carry anything at all. SECTION 4 -Walking A. Pain does not prevent me walking any distance. B. Pain prevents me walking more than one mile. C. Pain prevents me walking more than a quarter of a mile. D. Pain prevents me from walking more than 100 yards. E. I can only walk using a stick or crutches. F. I am in bed most of the time and have to crawl to the toilet. SECTION 5 -Sifting A. I can sit in any chair as long as I like. B. I can sit in my favorite chair as long as I like. C. Pain prevents me from sitting for more than one hour. D. Pain prevents me from sitting for more than half an hour. E. Pain prevents me from sitting for more than ten minutes. F. Pain prevents me from sitting at all. Patient Signature. SECTION 6 -Standing A. I can stand as long as I want without extra pain. B. I can stand as long as I want but it gives me exfra pain. C. Pain prevents me from standing for more than one hour. D. Pain prevents me from standing for more than half an hour, E. Pain prevents me fiom standing fbr more than ten minutes. F. Pain Drevents me from standine at all. SECTION 7 - A. Sleeping My sleep is never disturbed by pain. B. My sleep is occasionally disturbed by pain. C, Because of pain I have less than 6 hours sleep. D. Because of pain I have less than 4 hours sleep. E. Because ofpain I have less than 2 hours sleep. F" Pain prevents me from sleeping at all. SECTION8*SocialLife A. My social life is normal and gives me no exffa pain. B. My social life is normal but increases the degree of pain. C. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing, etc. D. Pain has restricted my social life and I do not go out as often. E. Pain has restricted social life to my home. F. I have no social life because ofpain. SECTION 9 - Traveling A. I can travel anywhere without pain. B. I can travel anywhere but it gives extra pain. C. Pain is bad but I manage joumeys over two hours. D. Pain restricts me to joumeys of less than one hour. E. Pain restricts me to journeys of less than 30 minutes. F. Pain prevents me llom traveling except to receive treatment. SECTION 10 - Changing Degree of Pain A.My pain is rapidly getting better. B. My pain fluctuates, but overall is definitely getting better. C. My pain seems to be getting befier, but improvement is slow at present. D. My pain is neither getting better nor worse. E. My pain is gradually worsening. F. Mv pain is rapidly worsening. Date Printed with J. C. T. Fairbank, P. B. Pynsent & S. Disney Prism Health Networks llllj7

12 NECK DISABILITY INDEX THIS QUESTIONNAIRE IS DESIGNED TO HELP US BETTER UNDERSTAND HOW YOUR NECK PAIN AFFECTS YOUR ABILITY TO MANAGE EVERYDAY -LIFE ACTIVITIES. PLEASE MARK IN EACH SECTION THE ONE BOX THAT APPLIES TO YOU. ALTHOUGH YOU MAY CONSIDER THAT TWO OF THE STATEMENTS IN ANY ONE SECTION RELATE TO YOU, PLEASE MARK THE BOX THAT MOST CLOSELY DESCRIBES YOUR PRESENT -DAY SITUATION. SECTION 1 - PAIN INTENSITY " I have no pain at the moment. " The pain is very mild at the moment. " The pain is moderate at the moment. " The pain is fairly severe at the moment. " The pain is very severe at the moment. " The pain is the worst imaginable at the moment. SECTION 6 CONCENTRATION " I can concentrate fully without difficulty. " I can concentrate fully with slight difficulty. " I have a fair degree of difficulty concentrating. " I have a lot of difficulty concentrating. " I have a great deal of difficulty concentrating. " I can't concentrate at all. SECTION 2 - PERSONAL CARE " I can look after myself normally without causing extra pain. " I can look after myself normally, but it causes extra pain. " It is painful to look after myself, and I am slow and careful. " I need some help but manage most of my personal care. " I need help every day in most aspects of self -care. " I do not get dressed. I wash with difficulty and stay in bed. SECTION 3 LIFTING " I can lift heavy weights without causing extra pain. " I can lift heavy weights, but it gives me extra pain. " Pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie. on a table. " Pain prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positioned. " I can lift only very light weights. " I cannot lift or carry anything at all. SECTION 4 WORK " I can do as much work as I want. " I can only do my usual work, but no more. " I can do most of my usual work, but no more. " I can't do my usual work. " I can hardly do any work at all. " I can't do any work at all. SECTION 7 SLEEPING " I have no trouble sleeping. " My sleep is slightly disturbed for less than 1 hour. " My sleep is mildly disturbed for up to 1-2 hours. " My sleep is moderately disturbed for up to 2-3 hours. " My sleep is greatly disturbed for up to 3-5 hours. " My sleep is completely disturbed for up to 5-7 hours. SECTION 8 DRIVING " I can drive my car without neck pain. " I can drive as long as I want with slight neck pain. " I can drive as long as I want with moderate neck pain. " I can't drive as long as I want because of moderate neck pain. " I can hardly drive at all because of severe neck pain. " I can't drive my care at all because of neck pain. SECTION 9 READING " I can read as much as I want with no neck pain. " I can read as much as I want with slight neck pain. " I can read as much as I want with moderate neck pain. " I can't read as much as I want because of moderate neck pain. " I can't read as much as I want because of severe neck pain. " I can't read at all. SECTION 5 HEADACHES " I have no headaches at all. " I have slight headaches that come infrequently. " I have moderate headaches that come infrequently. " I have moderate headaches that come frequently. " I have severe headaches that come frequently. " I have headaches almost all the time. SECTION 10 RECREATION " I have no neck pain during all recreational activities. " I have some neck pain with all recreational activities. " I have some neck pain with a few recreational activities. " I have neck pain with most recreational activities. " I can hardly do recreational activities due to neck pain. " I can't do any recreational activities due to neck pain. PATIENT NAME DATE SCORE [50] BENCHMARK -5 = Copyright: Vernon H. and Hagino C., Vernon H, Mior S. The Neck Disability Index: A study of reliability and validity. Journal of Manipulative and Physiological Therapeutics 1991; 14: Copied with permission of the authors.