Spine & Pain Center. On the diagram, shade the area where you feel pain. Put an X on the area that hurts the most.
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1 NEW PATIENT : : Physician: : Patient Label On the diagram, shade the area where you feel pain. Put an X on the area that hurts the most. What is your pain right now? Circle the number that best reflects your pain level No pain Moderate Worst possible # /18 rev Page 1 of 6
2 Have you seen other pain providers for current problem? _No _ Yes. If you replied yes, what was your reason for leaving? PAIN HISTORY: When did your pain begin? Was there a par cular incident, injury, accident, illness? No Yes, if so please explain: What does the pain feel like? Check all that apply: Pressure Nagging Tender Burning Itching Pinching Tingling Numbing Cramping S nging Spli ng Heavy Pulsing Throbbing Crushing Squeezing Shoo ng Dull Aching Radia ng Cu ng Sharp Stabbing Do you have? Check all that apply: Numbness Muscle spasms Skin discolora on Coldness Skin-sensi vity Tightness Tingling Pins and needles Weakness Increased swea ng Is your pain: Constant Unpredictable With increased ac vity If you have back pain how long can you: Sit: Stand: Lay flat on your back: Walk: Does the pain make it hard for you to: Check all that apply: Walk Sleep Sit Work Exercise Eat Be with family Enjoy life Have sex When is the pain worse? Check all that apply: Morning (6-9am) Midmorning (9-Noon) A ernoon (12-3 pm) Late a ernoon (3-6pm) Evening (6-9pm) Late evening (9-Midnight) Before next Dose of Meds Due Night (12-6am) With ac vity Can t predict How do you control flare-up pain? Check all that apply: Cold Heat Exercise Massage Acupuncture Sleep Alcohol Smoking Food Hypnosis Relaxa on Posi oning Self-medica on Prescrip on medica on Please explain if you checked above: Rate your pain score for each ques on. Circle all that apply. 0=no pain, 10=worst pain (circle answer for each) Rate your pain at its worst in the last 7 days: Rate your pain at its least in the last 7 days: Rate your pain on an average daily basis: # /18 rev Page 2 of 6
3 Patient Label Rate how pain has interfered with ac vi es: 0 = does not interfere, 10 = completely interferes: Rate your pain score for each ques on. (Only rate what applies, this sec on is op onal.) Rate the highest pain level that you can func on/live: General ac vity: Mood: Walking Ability: Sleep: Work outside home: Rela onships: Work inside the home: Cons pa on: Enjoyment of life: Sexual rela ons: Diagnos c History for current complaint: Please circle all that apply. X-Ray: MRI: CT Scan: EMG & NCV: Bone Density study: Other: THERAPEUTIC HISTORY: Have you seen other pain providers for current problem? No Yes If you replied yes, what was your reason for leaving? What procedures have been done to treat your pain? Check all that apply Trigger point injec ons Helpful Joint injec ons Helpful Nerve Blocks Helpful Epidural Steroids Helpful Radiofrequency Abla on Helpful Botox (Botulinum toxin) Helpful Spinal Cord S mula on Helpful Pain Pump Helpful Conserva ve treatment: Herbal/homeopathic Helpful TENS unit Helpful Bio-feedback Helpful Trac on Helpful Acupuncture Helpful Heat therapy Helpful Psychological programs Helpful # /18 rev Page 3 of 6
4 MEDICAL HISTORY: Do you now, or have you ever had any of the following? If so, provide details. No Yes Seizures or stroke No Yes Heart problems No Yes Lung or breathing problems No Yes Kidney problems No Yes Diabetes or high blood sugar No Yes GI problems (Ulcer, gastri s, hiatal hernia) No Yes Liver problems or hepa s No Yes Sleep Apnea No Yes Depression or Anxiety No Yes Cancer No Yes Hypertension No Yes Bleeding disorder or use of blood thinners No Yes Allergy to contrast or dye FAMILY HISTORY - Check all that Apply: Problem Mother Father Daughter Son Sibling(s) Anxiety Arthri s Depression Mental illness Diabetes Cancer Neurological DX Skeletal Disorder SURGICAL HISTORY - Please list the SURGERIES you have had and the year they were done. NAME OF SURGERY: DATE/YEAR: MEDICATIONS - Please list any MEDICATIONS you are currently taking (prescrip on or over-the-counter). # /18 rev Page 4 of 6
5 Patient Label CURRENT ALLERGIES: REACTION: SOCIAL HISTORY: Check all that apply: Occupa on: Currently working Re red Stopped due to pain Disabled Highest Degree Earned: Marital Status: Single Married Separated Divorced Domes c Partner Children: Number: Ages: Physical: Were you ever verbally or physically abused? Yes No Do you feel safe at home? Yes No History of preadolescent sexual abuse? Yes No Do you exercise? Yes No Rarely 1-2 mes/week 3-4 mes/week 5 or more What do you do for exercise? Psychological disease? Yes No ADD, ADHA, Obsessive-compulsive disorder, Bipolar Yes No Schizophrenia Yes No Depression Yes No If you answered yes, who is trea ng your condi on? Caffeine Use: Yes No How much? Tobacco use: Cigare es Cigar Pipe Never smoked Passive smoker Current smoker Former smoker When quit? Smokeless tobacco: Never Current Former When did you quit? Drug & Alcohol use: Alcohol use: Beer Wine Liquor Drinks per week/day/ month social? Recrea onal drug use Never Former Current Drug(s) used: Personal History of substance abuse? Alcohol Yes No DUI: Yes No Alcohol or Drug treatment program: Yes No Have you ever been treated in an Alcohol or drug treatment program? Yes No Have you a ended? AA or any other programs: Do you have an a orney because of a medical problem? Yes No # /18 rev Page 5 of 6
6 PAIN MEDICATIONS: Check the pain medica ons that you have used to treat your pain currently or in the past and check whether the medica on is helpful or not. Generic name (Brand name), does taking give helpful effects? SHORT ACTING OPIOIDS Tramadol (Ultram,Ultram ER)... Helpful Tapentadol (Nucynta)... Helpful Hydrocodone (Vicodin, Norco)... Helpful Morphine IR (MSIR)... Helpful Fentanyl (Ac q, Fentora)... Helpful Codeine (Tylenol 3#, 4#)... Helpful Oxycodone (Percocet, Roxicet)... Helpful LONG ACTING OPIOIDS CR Oxycodone (Oxycon n)... Helpful Morphine (AMS Con n, Kadian Avinza, Oramorph) Helpful Methadone (Dolophine)... Helpful Fentanyl patch (Duragesic)... Helpful Oxmorphone (Opana ER)... Helpful Levorphanol (Levodromoran)... Helpful Buprenorphine (Butrans)... Helpful Buprenorphine/Naloxone (Suboxone)... Helpful ANTICONVULSANTS Gabapen n (Neuron n)... Helpful Pregabalin (Lyrica)... Helpful Carbamazepine (Tegretol)... Helpful Topiramate (Topamax)... Helpful Leve racetam (Keppra)... Helpful MUSCLE RELAXANT Cyclobenzaprine (Flexeril)... Helpful Carisoprodol (Soma)... Helpful Metaxalone (Skelaxin)... Helpful Methocarbamol (Robaxin)... Helpful Tizanidine (Zanaflex)... Helpful Orphenadrine (Norflex)... Helpful Baclofen (Lioresal)... Helpful # /18 rev Page 6 of 6
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Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. Thank you for your cooperation. Patient
Name: (Last) (First) (Middle) Address: (City) (State) (Zip) Home: ( ) Work: ( ) Cell: ( ) Age: DOB: SS#: Height: Weight: Occupation:
2124 Route 35, Tel: (732) 788-0349 Holmdel, Fax: (877) 211-6276 NJ, E-mail: info@gramercypaincenter.com 07733. www.gramercypaincenter.com Date: Name: (Last) (First) (Middle) Home: ( ) Work: ( ) Cell: (
Subjective Medical History Information
Page 1 of 8 Date: Patient Account #: Patient Name: Insurance: Date of Birth: History of current condition 1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
NEUROPATHY CLIENT HISTORY AND LIFESTYLE INTAKE
NEUROPATHY CLIENT HISTORY AND LIFESTYLE INTAKE In order for us to completely evaluate your health status, please fill out the following pages. Be as thorough as possible. This allows us to assess your
PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS
PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS Advanced Spine Associates, P.A. NEW PATIENT MEDICAL HISTORY QUESTIONNAIRE Name Address City State Zip Age Date of Birth Sex M F Phone
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
Academy Asthma, Allergy, & Sinus Center
This questionnaire is designed to help patients with headaches. No doctors or pharmaceutical companies will profit from this questionnaire. Our only goal is to gather data on patients with headaches to
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
Managing Chronic Pain
Managing Chronic Pain What Is Chronic Pain? Everyone feels pain sometimes the sharp stab of a twisted ankle, the throb of a headache, the muscle soreness that comes from too much activity. This type of