* CC* PATIENT QUESTIONNAIRE
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1 Pain Center of Michigan * CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please quickly go over the following list of medical problems and check only those that pertain to you. HEAD frequent headaches migraine head injury dizziness or fainting E impairment of eyesight cataracts EARS hearing difficulty ringing/ buzzing earaches use of hearing aid (s) SE AND SINUSES frequent colds nasal stuffiness nose bleeds sinus problems MOUTH AND THROAT bleeding gums frequent sore throat hoarseness dentures OTHER: Cancer HIV Are you pregnant now? Y N RESPIRATORY asthma shortness of breath bronchitis emphysema/ chronic lung disease tuberculosis (TB) smoker years CARDIOVASCULAR irregular heart beat heart attack high cholesterol pacemaker PVD/ defibrillator congestive heart failure high blood pressure GASTROINTESTINAL loss of appetite recent change in bowel habits acid reflux ulcer obesity LIVER/ KIDNEY liver disease Hepatitis urinary problems kidney stones kidney disease recent change in bladder habits SURGICAL HISTORY MUSCULOSKELETAL aching muscles/ joints back/ neck problems swollen joints muscle weakness fibromyalgia arthritis SKIN itching, scaling rashes ENDOCRINE weight change thyroid disease diabetes endometriosis NERVOUS SYSTEM weakness numbness seizures speech impairment shaking difficulty walking neuropathy paralysis stroke PSYCHIATRIC depression trouble sleeping panic attacks/ anxiety other: PAIN MGT FORM CC (2/11) MED REC (3/11) 1
2 FAMILY HISTORY Are there any diseases that run in your family? If yes, please explain: Mother: Alive Deceased Age: Major Medical Problems: Father: Alive Deceased Age: Major Medical Problems: SOCIAL HISTORY Are you: Married Single Widowed Divorced Do you have any children? If yes, how many? Are they healthy? Live in a: Home Apartment Nursing Home Assisted Living Other: How many others live in your household? 4 or more Activities of daily living equipment: cane walker wheelchair Other Occupation: Full Time Part Time Retired Student Disability/ Social Security Is your pain related to a work or auto injury? Have you filed or plan to file for disability or social security? In either of the above circumstances, please answer the question below: Is there a lawsuit or attorney involved? Do you smoke? If yes, how much in a day? Are you a former smoker? If yes, when did you quit? Do you drink alcohol? Not at all Occasional Regularly 2-3 drinks or more a day If you drink, do you drink to relieve your pain? Have you ever used street drugs? Have you or your physician ever thought you had a problem controlling your pain medications? Have you every been sexually and/or physically abused? Are you currently experiencing sexual and/or physical abuse? Do you currently feel threatened in your environment? Have you ever thought of suicide? If yes, have you ever had a serious plan or attempted suicide? 2
3 * CC* MEDICATIONS (Prescription, over the counter, and herbal supplements) NAME DOSAGE HOW OFTEN WHAT DO YOU TAKE THIS FOR? ALLERGIES NAME REACTION 3
4 What do you expect after your visits to the Pain Center? Check the one best answer: A diagnosis (to help find the cause of the pain) A reduction of pain Help in coping with the pain A cure Don't know what to expect Where is your pain? Briefly describe how and when your pain started: PAIN ASSESSMENT Circle those activities that make your pain worse: Lying Cold (ice) Heat Standing Sitting Bending Other: Circle what makes your pain better: Medications Standing Sitting Lying Cold (ice) Heat Other: What medications have your tried in the past FOR YOUR PAIN? anti-depressants anti-seizures valium type drugs anti-inflammatories narcotics muscle relaxants Ultram Other If you are on narcotics for your pain, have they improved your general activity and level of function? No A Little A Moderate Amount A Lot Are you having these symptoms in your FEET OR HANDS? Burning Pain Skin sensitivity to light touching, e.g., stroking the skin, clothing or bedsheets? Abnormal skin color changes Abnormal skin temperature changes Abnormal sweating Abnormal swelling Decreased range of movement Tremor Changes in your hair or nail growth 4
5 * CC* TREATMENT HISTORY Have you ever had the following types of treatment for your pain and what was the result? Occupational Therapy Physical Therapy Chiropractic Deep Tissue Massage Acupuncture TENS Unit Psychiatric/ Psychology Counseling for Pain Biodfeedback Pain Management Program Back or Neck Injections Back or Neck Surgery Have you ever had any of the following investigate your pain problem? X-Rays MRI CAT Scan EMG Bone Scan FUNCTION AND QUALITY OF LIFE Please circle the number that best describes your ability to take part in the following activities. Can't Can do Can Do with difficulty Do Walk/ Stand for 20 minutes Sit for 20 minutes Drive a car/ Ride in a car Climb stairs Leave my house at least 3 times a week Engage in hobbies/ sports Do household chores Do any yard/ outside work Engage in sexual activities Shower/ bathe myself Shop for one hour Sleep for 4 continuous hours Get up from a laying or sitted position without help 5
6 Pain Diagram Shade in the areas on your body where you feel pain. Please circle all that apply to your pain. THROBBING, STABBING, SHARP, CRAMPING, HOT-BURNING, ACHING, HEAVY, TENDER, TIRING OTHER: Circle the number that best represents your pain. Zero is no pain, Ten is the worst pain you can imagine
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