Legacy Pain Management Center New Patient Questionnaire
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- Arthur Goodman
- 5 years ago
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1 Legacy Pain Management Center New Patient Questionnaire Please complete this form prior to your visit to allow us to make the best use of our time together. Primary Care Provider: Referring Physician: Other providers you currently see: Pain History 1. What is the diagnosis of your pain? (If known) 2. How did your pain begin? 3. When did your pain problems begin? (date of injury or your age when pain began) 4. Where is the pain? (Shade pain areas on the diagram below). Draw an arrow to the WORST area. Is the pain: (please check those that apply): [ ] aching [ ] burning [ ] constant [ ] pulsing [ ] shooting [ ] sharp [ ] stabbing 5. Do you have pain at all times? Y N (circle one) 6. What time of day does your pain bother you most? 1
2 7. On average, how severe is your pain from 0 to 10, with 0 being NO pain and 10 being WORST pain imaginable? 8. Do you have any Where? weakness? 9. Do you have any numbness? Where? 10. What makes your pain worse? 11. What makes your pain better? 12. What medications do you currently use for pain? (Please include dosage and frequency). Pain Treatment History 1. Circle all pain medications you have tried in the past: Name of Medication (Brand Name) Still Taking? Reason for stopping hydrocodone (Vicodin, Norco) oxycodone (Percocet, Oxycontin) methadone hydromorphone (Dilaudid) tramadol (Ultram) codeine (Tylenol #3) fentanyl patch (Duragesic) morphine (MSContin, Kadian) oxymorphone (Opana) cyclobenzaprine (Flexeril) methocarbamol (Robaxin) tizanadine (Zanaflex) metaxalone (Skelaxin) carisoprodol (Soma) gapapentin (Neurontin) pregabalin (Lyrica) duloxetine (Cymbalta) venlafaxine (Effexor) amitriptyline (Elavil) buprenorphine/naloxone (Suboxone) 2
3 2. Circle all other therapies you have tried: Pain therapies tried: Past? Current? Were they helpful? (Yes/No) Physical therapy Counseling Injections Other: Review of Systems Check any of the following symptoms you have experienced in the past month: Constitutional Cardiac Musculoskeletal Neurological, cont. Fatigue Chest pain Joint Pain Seizures Fevers Swelling Back Pain Tremors Joint swelling Weakness Eyes Gastrointestinal Muscle Pain Itching Constipation Mood Light sensitivity Diarrhea Skin Decreased concentration Vision changes Nausea Color change Depression Vomiting Rash Hallucinations Respiratory Wounds Anxiety Shortness of Breath Genitourinary Sleep difficulty Wheezing Problems urinating Neurological Considered suicide Incontinence Headaches Frequent urination Numbness Medical History 1. List ALL other MEDICATIONS and dosage (VERY IMPORTANT): 2. List any allergies to medications: 3. List all surgeries and their dates, if known: 4. Have you ever been diagnosed with sleep apnea? If yes, do you use a CPAP mask at night? 3
4 Do you use oxygen at night? Social History 1. Do you use tobacco? If yes, how much and when did you start? If no, have you in the past? 2. Do you drink alcohol? If yes, how much and how often? 3. Do you currently use any illicit substances? 4. Do you have a history of substance abuse? If yes, what substance and when was last use? 5. Marital status: [ ] Married [ ] Never married [ ] Live with spouse/partner [ ] Widowed [ ] Divorce/separated 6. Do you live alone or with others? [ ] Alone [ ] With others 7. Are you currently employed? [ ] Yes, how many hours per week and where? [ ] No, when did you last work? 8. Are you currently on disability? 9. Are you currently involved in a disability or legal claim? Psychological History 1. Have you even been diagnosed with anxiety, depression, panic attacks, or any other psychological condition? If yes, what/when? 2. Are you under the care of a mental health professional? If yes, who? 3. Do you have a history of prior physical or sexual abuse or other traumatic experiences? 4. Are you bothered by little interest or pleasure in doing things? 5. Have you been feeling down, depressed, or hopeless? 4
5 Family History Relationship Status Arthritis Cancer Chronic Pain Depression Diabetes High Blood Pressure High Cholesterol Obesity Substance Abuse Migraine Mother Alive Deceased Father Alive Deceased Maternal Grandmother Alive Deceased Maternal Grandfather Alive Deceased Paternal Grandmother Alive Deceased Paternal Grandfather Alive Deceased Other: Alive Deceased Thank you for taking the time to fill out this questionnaire! 5
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
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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
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ECPC Pain Specialists 2430 Emerald Place, Suite 103 Greenville, NC 27834 252-561-8218 ECPC Pain Specialists complies with applicable federal civil rights laws and does not discriminate on the basis of
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
Initial Pain Management Patient Questionnaire
Appt. Date: Appt. Time: Boston Out-Patient Surgical Suites North Tel Fax: 781-407-5892 Initial Pain Management Patient Questionnaire Dear New Pain Management Patient, Welcome to the New England Pain Management
2. Have your symptoms affected your ability to carry out your daily activities? YES NO
QUESTIONNAIRE Page 1 of 5 Date: Referring MD (Name, Address, Phone Number): Primary Care Physician (Name and Address, Phone Number): Reason for visit: 1. How long have you had symptoms? Describe your symptoms?