Initial Pain Questionnaire
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- Adele Atkinson
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1 Initial Pain Questionnaire Date: Name: Address: Last First Middle Initial Street Address City State Zip Home Phone Cell : Work: Referring Physician: Other Physicians: Age: PAIN HISTORY: What is the main problem for which you are seeking treatment? How long have you had your current pain? Years Months Weeks ONSET OF PAIN: How did your pain start? Injury at Work Injury, not at work Motor Vehicle Accident Illness, non-injury Treatment caused (e.g. radiation, surgery, etc) Undetermined If there is a precipitating event not mentioned, what was it?
2 PAIN INTENSITY: Circle Your Average Level of Pain In the Past Week (0 is no pain and 10 is severe): Using the same scale, what is your lowest pain score highest? TIMING OF PAIN: How often do you have pain (please check one)? Constantly (100% of time) Nearly constantly (60 to 95% of the time) Intermittently (30 to 60% of the time) Occasionally (less than 30% of the time) In general, during the past month, when has your pain been the worst? Morning Afternoon Evening Night No typical pattern PAIN/ SYMPTOM QUALITY: How would you describe your pain (please check all that apply): Burning Sharp Cutting Throbbing Cramping Dull/Aching Shooting Pressure-like Other: Do you have numbness (loss of sensation)? If so, where: Do you have pins and needles? If so, where: Do you have weakness? If so, where: Have you had fall in the last month? YES NO PAIN LOCATION: Please mark the location(s) of your pain on the diagram with an x. If whole areas are painful, please shade in these areas.
3 RELIEVING AND AGGRAVATING FACTORS: How do the following affect your pain? Please check one for each item. LYING DOWN STANDING SITTING WALKING EXERCISE RELAXATION BOWEL MOVEMENTS COUGHING/ SNEEZING ACTI VITIES AND PAIN How many blocks can you walk? How many minutes or hours can you walk? How many minutes or hours can you stand? DECREASE NO CHANGE INCREASE To assist walking, I use a : Cane Walker Wheelchair No assistance device Are you NOT able to perform any of the following activities? Going to Work Household Chores Yard work or Shopping Socializing with Friends Exercising PAIN TREATMENTS: Please check the responses to the treatment you have tried: TREATMENT NO RELIEF MODERATE RELIEF EXCELLENT RELIEF Surgery Traction Injections Physical Therapy Exercise TENS Heat Treatment Ice Treatment Psychotherapy Acupuncture Hypnosis Biofeedback Chiropractic Therapy
4 PAIN MEDICATIONS TRIED: Please check all medication you have tried: OPIOIDS: NSAIDs MUSCLE RELAXANTS Hydrocodone (Vicodin) Tylenol Soma Codeine Aspirin Flexeril Fentanyl (Duragesic) Motrin Baclofen Dilaudid (Exalgo) Naproxen Zanaflex Morphine/ MS Contin Indocin Robaxin Methadone Relafen Skelaxin Oxycodone (Percocet) Celebrex Valium (Diazepam) Oxycontin Toradol Butrans Meloxicam (Mobic) Suboxone Diclofenac Vioxx ANTI DEPRESSANTS OTHER Elavil (Amitryptilline) Paxil Topamax (topirimate) Pamelor (Nortryptilline) Prozac Tegretol (Carbamazepine) Desipramine Savella Trileptal Imipramine Cymbalta Neurontin Zoloft Effexor (Venlafaxine) Dilantin Depakote Lyrica PAST MEDICAL HISTORY: Have you had any of the following health problems (Please check all that apply)? Hypertension Coronary Artery Disease Chest Pain Heart Attack Diabetes Asthma or Wheezing Emphysema Kidney Disease Liver Disease Stroke Seizure or Epilepsy Bleeding Problem Depression Anxiety Thyroid Disease Arthritis (specify location) Cancer (what type) Other PAST SURGICAL HISTORY: DATE TYPE OF SURGERY
5 CURRENT MEDICATIONS FOR PAIN: NAME DOSE FREQUENCY CURRENT MEDICATIONS (Other than above): NAME DOSE FREQUENCY ALLERGIES: Please list the names of medications to which you are allergic. What type of reaction? I am allergic to contrast dye used for x ray? YES NO SOCIAL HISTORY: EMPLOYMENT: Your current or most recent occupation: Semi-skilled or Unskilled (i.e. Waitress, assembler) Skilled trade or clerical (eg. Carpenter, electrician, truck driver, secretary) Business executive or Managerial Professional (eg. Lawyer, teacher, nurse, physician, psychologist) Homemaker Other: Please specify
6 CURRENT EMPLOYMENT STATUS: Please check one: Employed Full-time Retired Employed Part-time Student Unemployed Homemaker LEGAL ISSUES: Please indicate any of the following claims you have filed related to your pain problem: Worker s Compensation Personal Injury/ Liability Social Security Disability Insurance Other: please specify SLEEP DISTURBANCE: Do you have difficulty falling asleep? Yes No Do you have difficulty staying asleep? Yes No Are you ever awakened by pain? Yes No FAMILY LIFE: Please specify living arrangements: Living alone Living with spouse/ partner Living with spouse/ partner and children Living with friends Living with other Living with children PSYCHOLOGICAL TREATMENT: Have you ever had psychiatric, psychological, or social work evaluation or treatments for any problem including your current pain? Yes No For what diagnosis were you treated and when? Please list your current therapist: SUBSTANCE ABUSE: Have you ever been a smoker? If you smoke, how many packs per day? For how many years did you smoke? Yes-Current Yes-In past Packs per day Years No-Never Do you have a history of alcoholism? Yes No Current Problem Have you abused prescription analgesics? Yes No Current Problem Cocaine or intravenous substance abuse? Yes No Current Problem How many years has it been since you abused alcohol or drugs? Years If you have a history of alcoholism, have you ever been enrolled in Alcoholics Anonymous? Yes No When? If you have a history of substance abuse, have you ever been in a detoxification program? Yes No When?
7 FAMILY HISTORY: Please specify any medical or psychiatric conditions common in your family and who suffers with these ailments: Condition: Condition: Condition: Specific family member(s): Specific family member(s): Specific family member(s): REVIEW OF SYSTEMS: Please check all items you feel apply to you: Recent gain of weight: pounds over weeks/months/years Recent loss of weight: pounds over weeks/months/years Fever Dizziness Difficulty swallowing Loss of Consciousness Difficulty walking Double or blurry vision Seizures Muscle weakness Nausea Easy or excessive bruising Vomiting Easy or excessive bleeding Constipation Rash Diarrhea Diabetes Adrenal Disease Genital pain Hypothyroidism Chest pain Hyperthyroidism Heart palpitations Joint stiffness Shortness of Breath Decreased Range of Motion Wheezing Pain in extremity (specify) Memory loss Swelling (specify) Difficulty urinating
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Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
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THE METROPOLITAN NEROSURGERY GROUP PATIENT REGISTRATION Today's Date: / / Primary Care Physician: PCP Address:
THE METROPOLITAN NEROSURGERY GROUP PATIENT REGISTRATION Today's Date: / / Primary Care Physician: PCP Address: PCP Phone: PATIENT INFORMATION LAST NAME FIRST NAME MI Mr. Mrs. Miss Ms. Single Married Widow
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire Please complete this questionnaire before your scheduled appointment and bring this form with you the day of your visit. Patient
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
The UW Pain Treatment and Research Center takes a holistic approach to your pain care.
Pain Treatment and Research Center 5249 East Terrace Drive Madison, WI 53718 Phone: (608) 263-9550 Dear Patient: The UW Pain Treatment and Research Center takes a holistic approach to your pain care. You
Please fill out this form as completely as possible. This information will determine how we treat your pain problem.
Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your
Thank you for choosing Therapy Works to assist you with your current condition.
Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail Address
Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State
Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married
CERVICAL Orthopedic Specialists of Louisiana Pierce D. Nunley, MD PERSONAL INFORMATION. Patient Name:
PERSONAL INFORMATION (Please Print or Type) Patient Name: Last First MI Registration Date: / / Birthdate: / / Age: Social Security #: - - Sex: Address: Apt. # Street Telephone Numbers: ( ) Occupation:
NEW SPINE PATIENT QUESTIONNAIRE
NEW SPINE PATIENT QUESTIONNAIRE Patient Name (please print) Date Age Birthdate Gender: Male Female Primary Care Doctor Phone# Referring Doctor Phone# We routinely send a copy of all clinic notes to your