PAIN HISTORY. Please describe your pain:
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- Laurel Houston
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1 Name: Date: PAIN HISTORY Please describe your pain: List surgeries/hospital admissions and dates (Skip if you have already provided this information on Medical History Questionnaire): Please list current medications if you haven t done so on the Medical History Questionnaire: Name Purpose Amount Frequency Effectiveness List any medication allergies: Check the following conditions that apply to you: ü ü ü ü ü Diabetes Cancer Hepatitis Fractures Vision problems COPD/Respiratory Vascular Disease Osteoporosis Back/neck injury Ménière's/Hearing loss CHF/MI/Heart problems Neuropathy Arthritis Fusion Dizziness/vertigo CVA/TIA/Stroke Fibromyalgia Jt. Replacement Headaches Anxiety Pacemaker MS/Parkinson s Skin problems Head injury Depression High blood pressure Muscle weakness Seizures Incontinence GI/Crohn s/ibs Other:
2 When did your pain start? What was the cause of your pain? Auto Work Sports Daily life Surgery Other: What diagnostic tests have you had? X-rays CT Scan Bone Scan MRI Arthrogram Discogram EMG Other: Results of diagnostic testing: Use this scale to answer the questions below: (no pain) (medium pain) (worst pain imaginable) Rate your average daily level of pain: Rate your pain doing daily tasks: Rate your worst level of pain: Rate your pain at rest: Rate your best level of pain: Since the onset of your symptoms, are the symptoms: improving worsening not changing come and go constant What is the worst time of the day for you? mornings afternoons evenings sleeping Please shade the areas on the anatomical figures below where you feel your pain:
3 Please check off all of the descriptors below that characterize your pain: ü ü ü Flickering Tingling Annoying Quivering Itchy Troublesome Pulsing Smarting Miserable Throbbing Stinging Intense Beating Dull Unbearable Pounding Sore Jumping Hurting Spreading Flashing Aching Radiating Shooting Heavy Penetrating Prickling Tender Piercing Boring Taut Tight Drilling Rasping Numb Stabbing Splitting Drawing Lacinating Squeezing Sharp Tiring Tearing Cutting Exhausting Cool Lacerating Sickening Cold Pinching Suffocating Freezing Pressing Fearful Nagging Gnawing Frightful Nauseating Cramping Terrifying Agonizing Crushing Punishing Dreadful Tugging Grueling Torturing Pulling Cruel Wrenching Vicious Hot Killing Burning Wretched Scalding Blinding Searing PRI
4 FUNCTIONAL LIMITATIONS Instructions: Please check the level of difficulty you have for each activity. Able to do without any difficulty Able to do with little difficulty Able to do with moderate difficulty Able to do with much difficulty Unable to do at all Not applicable 1. Lying flat 2. Rolling over 3. Moving (lying to sitting) 4. Sitting 5. Squatting 6. Bending/stooping 7. Balancing 8. Kneeling 9. Walking (short distance) 10. Walking (long distance) 11. Walking outdoors 12. Climbing stairs 13. Hopping 14. Jumping 15. Running 16. Pushing 17. Pulling 18. Reaching 19. Grasping 20. Lifting 21. Carrying What other changes have you or your family members had to make in response to your pain?
5 What do you do to prevent your pain from getting worse? REACTIONS TO YOUR PAIN Please state your diagnosis to the best of your ability: How do you feel about your diagnosis (e.g., is it accurate or inaccurate)? Do you understand and/or accept your diagnosis? If you didn t have pain, what would you be doing differently? What do you think your prognosis (future outcome) is?
6 What do you want to accomplish from this referral? Please use the scale below average to the affect of your pain on the following areas of your life: 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (no effect) (medium effect) (completely controls) Mood (e.g., anxiety, depression, stress) % Sleep % Relationship with others % Appetite % Walking % Enjoyment of life % Working % Activities (e.g., housework, chores, hobbies) % þ Treatment Modality Provider Dates or # of visits Was this helpful? Physical Therapy (land) Pool Therapy Occupational Therapy Massage Acupuncture Chiropractic Dry Needling Prolo Therapy TENS/Interferential Unit Trigger Point Injections Steroid Injection(s) Facet or SI Injections Nerve Block(s) Epidural Steroid Injection(s) Sympathetic or Stellate Ganglion Block(s) Psychotherapy/Counseling Biofeedback Other:
7 PCS Listed below are 13 statements describing different thoughts and feelings that may be associated with pain. Using the following scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain. 0 not at all 1 to a slight degree 2 to a moderate degree 3 to a great degree 4 all the time When I m in pain Rating # Thought/Emotion 1 I worry all the time about whether the pain will end. 2 I feel I can t go on. 3 It s terrible and I think it s never going to get any better. 4 It s awful and I feel that it overwhelms me. 5 I feel I can t stand it anymore. 6 I become afraid that the pain will get worse. 7 I keep thinking of other painful events. 8 I anxiously want the pain to go away. 9 I can t seem to keep it out of my mind. 10 I keep thinking about how much it hurts. 11 I keep thinking about how badly I want the pain to stop. 12 There s nothing I can do to reduce the intensity of the pain. 13 I wonder whether something serious may happen. TOTAL
8
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Patient Intake Form. Demographic & Contact Information. Address Primary Phone Cell Phone. Address 2 Work Phone Home Phone
Patient Intake Form Brink Chiropractic Clinic 1047 Main St Sanford, ME 04073 Phone: 207-324-5753 Fax: 207-324-8354 Once completed, please save this document to your computer or device and email the document
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?