Medical History. Instructions. My telephone number is: 1 Tools Medical History
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1 Medical History Instructions To do the best possible job with your pain, your doctor needs details about your history, including current and past medical problems, medications, health habits, and family history. For questions that ask about how you feel, please give your best answer yourself. The information about your past medical history may be gathered from both you and your family members. My name is: Date: My telephone number is: 1 Tools Medical History
2 Pain History Questionnaire Please give your best answer to the following questions: 1. Where is the pain? (for example: knees, joints, back, head). Does it seem to move anywhere else? 2. How and when did the pain begin? 3. Tell us all you can about the pain: What does it feel like (burning, tingling, shooting, sharp, aching), what time of day does it occur, what makes it start, what makes it better, and what makes it worse? 4. Please tell us all you know about previous evaluations of your pain. Particularly, tell us about any X-rays, MRIs, or other procedures done to find out the cause. 2 Tools Medical History
3 Pain History Questionnaire, continued 5. What have you been told is causing your pain? 6. Have you had any surgeries or procedures for treatment of your pain? Don t forget therapies and injections. If so, tell us what, where, and by whom. Also tell us how well the treatments worked. 7. What medications have you taken for the pain and how well have they worked? What medicines didn t work out for you and why? (Include both prescription and overthe-counter medicines, creams and herbals. Start back when you first developed your pain problem.) 8. If you have any specific ideas of what should be done for your pain, please write them here. 3 Tools Medical History
4 Persistent Pain Questionnaire Please choose the best response to the following questions. 1. How much does your pain interfere with walking? 2. How much does your pain interfere with enjoying your life (socializing, travel, hobbies, and work)? 3. How much does your pain interfere with shopping? 4. How much does your pain interfere with driving? 5. How much does your pain interfere with your ability to exercise? 6. How much does your pain interfere with taking a bath? 7. How much does your pain interfere with getting to the toilet on time? 8. How much does your pain interfere with your ability to think clearly? 9. How much does your pain interfere with your sleep? 10. How much does your pain interfere with your appetite? 11. How much does your pain interfere with your mood and spirits? 12. How much does your pain interfere with your relationships with family and friends? 13. How much does your pain interfere with your energy? 4 Tools Medical History
5 Past Medical History Have you been affected by any of the following problems or conditions? If so, when was it first found? Condition When? Yes No Headache TMJ or jaw pain Dental pain Neck pain Problems swallowing Chronic lung problems Chest pain Heart trouble Stomach or bowel trouble Pelvic pain Arthritis Fibromyalgia Shoulder or arm pain Back pain Hip or knee pain Muscle pain Diabetes Nervous system disorder Depression Nervousness, panic attacks Trouble sleeping Liver or kidney trouble 5 Tools Medical History
6 Current Medical History Please list the medical conditions currently affecting you or that you are currently receiving treatment for. Condition When Did It Begin? Psychiatric History Please list all psychiatric conditions or treatments you have had, with the approximate date of onset for each. Condition or Treatment Date 6 Tools Medical History
7 Operations Please list all operations with the date of the operation. Operation Date Hospitalizations List the reason and month/year for hospitalizations in the past 10 years. Reason Month/Year 7 Tools Medical History
8 Family History Please indicate which family members have had any of the following medical conditions (give the relationship to you, not the relative s name). Condition Family Member(s) Diabetes Arthritis Depression Anxiety Nervous system problem Pain problems Health Habits If you ever smoked, how many packs per day and for how many years? If you no longer smoke, when did you quit? Have you ever used street drugs? No Yes Do you drink alcoholic beverages on most days? No Yes If yes, how many drinks per day, usually? (1 drink is 1 beer, 6 oz of wine, or 2 oz of hard liquor) Have you ever been a heavy drinker (6 drinks a day or more)? No Yes 8 Tools Medical History
9 Exercise History In the last few months, how much time each week did you spend in at least moderate exercise? Less than 15 min min min. More than 120 min. Moderate exercise can be walking, bicycling, swimming, or heavy housework (vacuuming, cleaning). For example: 30 minutes per day, 3 days a week would be 90 minutes total for the week. What kind of exercise activities do you do? Social Support and Resources 1. How much help can you expect from family or friends when you are sick? All I need Daily help A few times a week Once a week Less than once 2. Who is the person that usually helps you when you are sick? 3. Do you hire people to help you at home? Yes No 4. Do you have enough money to afford the little things that make life pleasant? 9 Tools Medical History
10 Medication History Please list all prescription medicines that you are currently taking. Name of Medication Strength and Times per Day Please list all over-the-counter medicines that you are currently taking at least once a week. Name of Medication Strength and Times per Day 10 Tools Medical History
11 Review of Symptoms Have you been bothered by any of the following problems in the past few months? Please describe any problems briefly, with approximate dates. If you need more room, write on the back of the sheet. Leave the line empty if the problem has not occurred. Problem Vision or hearing problem Lack of energy Decreased alertness and fatigue Dizziness and unsteadiness Passing out spells Falls or near falls Dry mouth Chest pain or discomfort Reflux or stomach pain Constipation Nausea Change in appetite Weight change Swelling Night sweats Trouble with sleep Depression Trouble with urination Confusion Sexuality problem Description, Date(s) 11 Tools Medical History
Medical History. Instructions. My telephone number is: 1 Tools Medical History
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