INITIAL COMPREHENSIVE PAIN QUESTIONNAIRE
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1 INITIAL COMPREHENSIVE PAIN QUESTIONNAIRE Name: DOB: Address: Phone number: Referring Physician name: PAIN HISTORY: Was the pain a result of a particular incident (injury, accident, illness): No Yes (please explain) If the pain started after an injury, did it occur while at work: No Yes, date: Is there an active worker s compensation case related to the injury: No Yes Is there any active litigation / lawsuits related to the injury: No Yes Do you have any existing pain diagnoses (fibromyalgia, CRPS): No Yes (please provide detail) When did the pain start: Where is your pain: on the diagram below, please shade the area where you feel pain and put an X on the area that hurts the most. What level is your pain: please circle your best, worst and average pain scores.
2 What level of pain can you live and function at: What is the timing of your pain: please check all that apply. Constant Intermittent / Episodic Worse with / during What does the pain feel like: please check all that apply. Sharp Stabbing Stinging Electric Burning Radiating / shooting Dull Aching Throbbing Cramping Gnawing Squeezing /crushing Pressure Pinching Pulsing Numbing / Tingling Other What symptoms do you have along with your pain: please check all that apply. Numbness Tingling Weakness in arms Weakness in legs Loss of urine control Loss of bowel control Balance problems Falls Dropping things Muscle spasms Skin discoloration Hair changes Nail changes Temperature changes Excessive sweating Extreme sensitivity to touch Does the pain make it hard for you to: please check all that apply. Enjoy life Work Take care of yourself / perform simple chores Sleep Pain Medication History: please check the pain medications that you have used to treat your pain currently or in the past. Medication Check If Check Check Please List Any Side Generic Name Dose Current If If Not Effects (BRAND NAME) Use Helpful Helpful Anti-Inflammatories Acetaminophen (TYLENOL) Aspirin Ibuprofen (ADVIL, MOTRIN) Naproxen (ALEVE, NAPROSYN) Diclofenac (ARTHROTEC) Indomethacin (INDOCIN) Etodolac (LODINE) Ketoralac (TORADOL) Meloxicam (MOBIC) Piroxicam (FELDENE) Nabumetone (Relafen) Other: Anticonvulsants Gabapentin (Neurontin) Pregabalin (LYRICA) Carbamazepine (TEGRETOL) Topiramate (TOPAMAX) Levetiracetam (KEPPRA) Antidepressants Amitriptyline (ELAVIL) Nortriptyline (PAMELOR) Desipramine (NORPRAMIN)
3 Imipramine (TOFRANIL) Doxepin Trazodone (OLEPTRO) Serotonin / Norepinephrine Duloxetine (CYMBALTA) RIs Venlafaxine (EFFEXOR) Milnacipran (SAVELLA) Antipsychotics Olanzapine (ZYPREXA) Haloperidol (HALDOL) Ziprasidone (GEODON) Muscle Relaxants Clyclobenzaprine (FLEXERIL) Carisoprodol (SOMA) Metaxalone (SKELAXIN) Methocarbamol (ROBAXIN) Tizanidine (ZANAFLEX) Orphenadrine (NORFLEX) Baclofen (LIORESAL) Benzodiazepines Diazepam (VALIUM) Alprazolam (XANAX) Lorazepam (ATIVAN) Clonazepam (KLONOPIN) Chlordiazepoxide (LIBRIUM) Short Acting Opioids Tramadol (ULTRAM, ULTRAM Tapentadol ER) (NUCYNTA) Hydrocodone (VICODIN, NORCO) Oxycodone (PERCOCET, ROXICET) Meperidine (DEMEROL) Hydromorphone (DILAUDID) Fentanyl (ACTIQ, FENTORA) Codeine (TYLENOL #3, #4) Long Acting Opioids CR Oxycodone (OXYCONTIN) LA Morphine (MS CONTIN, KADIAN, Methadone AVINZA, (DOLOPHINE) Fentanyl Patch (DURAGESIC) LA Oxmorphone (OPANA ER) Levorphanol (LEVODROMORAN) Buprenorphine (BUTRANS) Buprenorphine /Naloxone (SUBOXONE) Pain Interventions History: please check all that apply. Name Of Intervention Check If Helpful Check If Not Helpful Procedures Trigger point injections Botox injections Nerve blocks
4 Facet injections Radiofrequency ablation SI joint injections Piriformis injections Epidural injections Shoulder injections Hip injections Knee injections Foot injections Spinal cord stimulator trial Spinal cord stimulator implant Intrathecal (spinal) pump Spine sugery Conservative Therapies Physical therapy Occupational therapy Aqua therapy Yoga, Tai Chi, Pilates Chiropractic treatment Osteopathic treatment Homeopathic treatment Heat Cold Braces / Orthotics TENS Unit Massage Acupuncture Biofeedback Cognitive behavioral therapy Meditation Psychological programs Other: REMAINING MEDICAL HISTORY: Past Medical History: please list active medical conditions currently being monitored or treated. Past Surgical History: please list in chronological order. Year Type of Surgery
5 Social History: Occupation: Working full time Working part time Unemployed Disabled Retired Highest degree of education earned: Marital status: Who do you live with: Exercise: what kind and how often: Tobacco use: No Yes In the past How many pack-years: Alcohol abuse: No Yes In the past In the family; how much: Recreational drug use: No Yes In the past In the family; type(s): Prescription drug abuse: No Yes In the past In the family; type(s): Physical abuse history: No Yes In the past Sexual abuse history: No Yes In the past Suicide history: No Considered Planned Attempted Family History: please list medical conditions among first-degree relatives. Other Medications: please list other non-pain related medications you currently use. Blood Thinning Medications: please check all that you are currently taking or have taken recently. Aspirin Aspirin, Dipyridamole (AGGRENOX) Heparin Low Molecular Weight Heparin (LOVENOX) Warfarin (COUMADIN) Apixaban (ELIQUIS) Edoxaban (SAVAYSA) Rivaroxaban (XARELTO) Dabigatran (PRADAXA) Fondaparinux (ARIXTRA) Clopidogrel (PLAVIX) Abciximab (REOPRO) Eptifibatide (INTEGRILIN) Ticrofiban (AGGRASTAT) Prasugrel (EFFIENT) Ticagrelor (BRILINTA) Cilostazol (PLETAL) Abciximab (REOPRO) tpa, urokinase, alteplase, streptokinase Other: Allergies: please list medication and corresponding reactions. Medication No known drug allergy Reaction
6 Are you allergic to contrast dye: No Yes, please describe reaction REVIEW OF SYSTEMS: please check all that currently applies to you. General: Fever, chills, night sweats Excessive sweating Fatigue Poor sleep Loss of appetite / weight loss Weight gain Cardiovascular: Chest pain Palpitations Fainting Difficulty breathing while lying down Swelling of the legs Gastrointestinal: Abdominal pain Nausea Vomiting Diarrhea Constipation Blood in stool Bowel incontinence Genital-Reproductive: Pelvic pain Groin pain Decreased sexual desire Decrease ability to achieve erection Irregular / heavy menstrual periods Head, Eyes, Ear, Nose, Throat: Headaches Dizziness Blurred vision Ringing in ears Hoarseness Difficulty swallowing Respiratory: Shortness of breath Cough Wheezing Pauses in breathing during sleep Excessive daytime sleepiness Urinary: Pelvic pain Flank pain Pain or burning on urination Inability to urinate Urgency to urinate Urinary incontinence Hematologic / Endocrine: Easy bruising / bleeding History of blood clots Cold intolerance Heat intolerance
7 Musculoskeletal: Join pain Joint instability Joint swelling Joint redness / warmth Muscle spasms / pain Psychiatric: Depression Anxiety Difficulty with thinking / problem solving Suicidal / homicidal thoughts Neurologic: Seizures Strokes Numbness / tingling Weakness or paralysis in arms or legs Loss of balance / loss of coordination Skin: Rash Discoloration Itching Hair loss
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Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
INITIAL PATIENT FORM
Patient : INITIAL PATIENT FORM Reason for your visit: Visit Date: Left CIRCLE AREA(S) OF CONCERN: Right TOP/BOTTOM OUTSIDE INSIDE Type of pain: Sharp Burning Soreness Tightness Stabbing Numbness Aching
Tapering Injured Workers off Prescription Drugs
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DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:
Patient Name: Patient Date of Birth: Appointment Date: Please mark and/or notate the areas of your body which are affected by pain. RIGHT RIGHT LEFT LEFT RIGHT LEFT RIGHT RIGHT LEFT LEFT RIGHT LEFT For
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
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?
Managing Pain after Transplant Denice Economou, RN,MN,CHPN,AOCN
Managing Pain after Transplant Denice Economou, RN,MN,CHPN,AOCN Oncology Clinical Nurse Specialist, Senior Research Specialist City of Hope Definition of Pain Pain is an unpleasant sensory and emotional
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell