Keith A. Perry M.D. Board Certified Pain Specialist

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1 Keith A. Perry M.D. Board Certified Pain Specialist 14 Cedar Swamp Rd, Smithfield RI Phone ; fax Thank you for taking time to answer this questionnaire. If the form is not filled out completely you will not be seen and your appointment will have to be rescheduled. Name: Nickname: Address: City, State, ZIP Code: Home Phone: ( ) Cell: ( ) Work Phone: ( ) Date of Birth SS#: Sex: M F Ethnicty Race: White Black Native American Asian Other Unknown Preferred Language Who to call in case of emergency: Name Ph# Relationship 1. Who referred you to the pain clinic? 2. What is his/her phone number? 3. Who is your primary doctor? 4. What is his/her phone number? 5. Name of Pharmacy you use? Phone # 6. Are you allergic to: Latex? Yes No Nuts? Yes No Vaccines Yes No Other allergies 7. When did your pain problem begin? Month Year 8. Describe your pain problem? 9. Describe when your pain problem occurs? (i.e., Is it constant, intermittent, only at night, etc.?) 10. How did your pain problem first start? (Car accident? Fall? Job-related injury? Etc.) 11. Estimate the number of visits to health providers for your pain problem you have made in the last year. 12. Have you been hospitalized for your pain in the past? Yes No If yes, how many times this year?

2 13. Are you involved in legal action related to your pain problem or considering it in the future? Yes No If yes, describe the current state of litigation. 14. Please circle the level of your primary pain from 0 (no pain) to 10 (worst painimaginable) for the following: PRESENT level of pain: (No pain) (Worst pain imaginable) WORST pain you ve had: (No pain) (Worst pain imaginable) LEAST pain you ve had (No pain) (Worst pain imaginable) 15. Using the same scale, what level of pain is ACCEPTABLE for you? (No pain) (Worst pain imaginable) 16. Use the figures below to shade in the areas where you have pain. If your pain moves around, put an X where it starts and draw an arrow to where it spreads. PHYSICIAN S NOTES:

3 17. Look at the following categories of words used to describe pain. From each group of words circle the one word that best describes your primary pain. If there is no word in a numbered group that seems to describe your pain, then skip that group Flickering Jumping Pricking Sharp Quivering Flashing Boring Cutting Pulsing Shooting Drilling Lacerating Throbbing Stabbing Beating Lancinating Punding Pinching Tugging Hot Tingling Pressing Pulling Burning Itchy Gnawing Wrenching Scalding Smarting Cramping Searing Stinging Crushing Dull Tender Tiring Sickening Sore Taut Exausting Suffocating Hurting Rasping Aching Splitting Heavy Fearful Punishing Wretched Annoying Frightful Grueling Blinding Troublesome Terrifying Cruel Miserable Vicious Intense Killing Unbearable Spreading Tight Cool Nagging Radiating Numb Cold Nauseating Penetrating Drawing Freezing Agonizing Piercing Squeezing Dreadful Torturing 18. If the above words do not describe your pain, describe in your own words what your pain is like. PHYSICIAN S NOTES:

4 19. Are there things that influence your pain? Please check all that apply. INFLUENCING FACTORS RELIEVES WORSENS Exercise Walking Massage Sitting Standing Touch Heat Pack Ice Pack Temperature (hot) Temperature (cold) Weather Bright lights Eating Alcohol Emotional stress Urination Defecation Noise People Music Sleeping Sexual activity Menstrual cycle Medicines Rolling in bed Moving from sitting to standing Stairs Other NO DIFFERENCE COMMENTS PHYSICIAN S NOTES:

5 20. What treatments have you received for pain in the past? Please check if treatment was helpful or not helpful. TREATMENT HELPFUL NOT HELPFUL COMMENTS Surgery Nerve block Steroid injection Acupuncture Trigger point injection TENS unit Heat / ice treatment Biofeedback Hypnosis Relaxation training Counseling Physical Therapy Traction Chiropractic treatment Occupational therapy Other (explain) 21. Please list all past surgeries and hospitalizations: DATE PROCEDURE DOCTOR FACILITY

6 22. Do you have history of: Motion sickness? Yes No Postoperative nausea/vomiting? Yes No Complications with anesthesia? Yes No If yes, explain 23. Have you had any of the following tests performed within the past 24 months? TEST DATE FACILITY WHERE TEST WAS DONE ORDERING PHYSICIAN X-ray film CT scan MRI Laboratory EMG Myelogram 24. Are there areas of your life that have been affected by your pain problem? Check and explain ALL that apply. Sleep Appetite Relationships Work Finances Physical activity Use of alcohol Use of recreational drugs Emotions Concentration Other 25. What best describes your present use of pain medications? Definitely increasing Increasing slightly Same as always Decreasing slightly Definitely decreasing Not applicable

7 26. Please check ALL that apply. GENERAL Chills Weight loss or gain Fatigue Daytime sleepiness NEURO Headache Passing out Weakness (legs, arms) Numbness, tingling Stroke Paralysis Epilepsy / Seizures Polio Difficulty balancing Difficulty walking Other neurological diseases EYES Eye pain Flashing Lights Double vision Blurry vision Glaucoma Vision Changes RESPIR. Chronic cough Wheezing Shortness of breath Emphysema Asthma Pneumonia Coughing Blood Productive cough Tuberculosis CARDIAC Chest pain / Angina Palpitations Awaken short of breath Awaken short of breath Phlebitis Blood clot History of a heart attack Heart murmur Mitral valve prolapse / Valve replacement Pacemaker Heart stents Irregular heartbeat High blood pressure Peripheral vascular disease Ankle swelling ENT Hearing loss Ear noises Dizziness Lightheadedness Nasal congestion Sinus pressure Problem snoring/apnea Hoarseness ENDOCRINE Thyroid Disease Diabetes Excessive thirst Heat / cold intolerance GI GU Difficulty swallowing Heartburn Abdominal pain Nausea/vomiting Bowel irregularity / Bowel problems Rectal bleeding Hepatitis / liver infection Jaundice Chronic diarrhea/constipation Other Kidney problems Frequent urination Painful urination Blood in urine Prostate problems Erectile dysfunction Dark urine

8 PSYCH / SOCIAL Depression Anxiety or panic Other psychiatric disorders Do you have support from family and friends when you need it? Yes No Do you feel threatened or unsafe in your home from anyone? Yes No Are there any religious or cultural preferences we should know about? MSK Joint aches Swelling of joints Redness of joints Gout Rheumatic fever Osteoporosis Osteoarthritis Rheumatoid arthritis Muscle aches Other SKIN Itching Rash Hives Skin or hair changes HEMO Anemia Easy bruising Bleeding disorder AIDS/HIV positive History of cancer: 27. Are you pregnant or planning to become pregnant? Yes No 28. What is your current marital status? Single Living with significant other Married Divorced Widowed Separated 29. What was your marital status when your pain problem began? Single Living with significant other Married Divorced Widowed Separated 30. What is the highest level of education you ve finished? 31. List the names and ages of all the people who live with you: 32. Are you currently working? Yes No Retired If yes, describe your occupation: 33. Is this the same occupation you had before your pain started? Yes No 34. If you are not working, has the pain forced you to stop working? Yes No 35. If you are not working, what type of work did you do before your pain became a problem? 36. Does your spouse work? Yes No If yes, what s your spouse s occupation? 37. Are you being treated under Worker s Compensation? Yes No

9 38. Are you currently receiving disability benefits? Yes No 39. Do you smoke? Yes No If yes, what do you smoke? How many packs per day? How long have you been smoking? 40. Do you drink alcoholic beverages? Yes No If yes, how many ounces for average daily use? 41. Do you drink beverages with caffeine (i.e., coffee, tea, soda, etc.)? Yes No If yes, how many 8-oz glasses for average daily use? 42. Do you use recreational drugs? Yes No If yes, what do you use? How much/how often do you use it/ How long have you been using it? 43. Do you exercise on a regular basis? Yes No If yes, what type of exercise and how many times per week? 44. Current Height Current Weight Lb 45. FAMILY HISTORY: Please check Yes or No box to indicate whether any relatives have any of the following illnesses. If yes, please indicate which relative(s) have the problem. Heart problems / murmurs Yes No Allergies Yes No Diabetes Yes No Cancer Yes No Bleeding disorder Yes No Anesthesia Problems Yes No PHYSICIAN S NOTES: Patient s signature Date Physician s signature Date

10 Keith A. Perry M.D. Board Certified Pain Specialist 14 Cedar Swamp Rd, Smithfield RI Phone ; fax Outpatient Medication Form Patient Name: List all Prescription, non-prescription (Aspirin, Antacids), Herbals (Ginseng, Ginko, St.John s Wort) and Vitamins. Please include strength of all medications, and all medications you take as needed (examples Pain or sleep medication, Nitroglycerin) Name of Medication and Strength Directions (include route) Reason for taking and Prescriber s Name

NECK PAIN QUESTIONNAIRE

NECK PAIN QUESTIONNAIRE This questionnaire is designed by your doctor to answer specific questions. Please answer each question as completely as possible. Name: Date: 1. How long have you had neck pain?