PLEASE COMPLETE BOTH FRONT AND BACK OF THIS FORM I >

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1 Date: PATIENT DATA FORM Please complete this form thoroughly. If a particular section does not apply to you, please indicate so. This information is vital in order to schedule an appointment at United Pain Center. We will not schedule an appointment unless we have all of this information. Thank you. 1. PATIENT INFORMATION NAME. DATE OF BIRTH. /_----'/ Sex M F APT# ADDRESS CITY COUNTRY STATE. ZIP RACE. OF ORIGIN. HOME WORK PHONE# PHONE# CELL# PREFFERED # TO CONTACT YOU SS# RELIGION MARITAL STATUS (circle): Single Married Widow(ed) Divorced Separated Significant Other/Partner 2. PATIENT EMPLOYMENT INFORMATION EMPLOYMENT STATUS: FULL PART-TIME SELF NOT EMPLOYED RETIRED EMPLOYER CITY PHONE OCCUPATION 3. SPOUSE/PARTNER RELATIONSHIP TO PATIENT ṆAME SS# --- DATE OF BIRTH. / / 4. EMERGENCY CONT ACT COTHER THAN LISTED) RELATIONSHIP TO PATIENT NAME HOME PHONE# CELL# 5. MEDICAL INFORMATION REFERRING PHYSICIAN DIAGNOSIS ( BODY PART TO BE TREATED), PLEASE COMPLETE BOTH FRONT AND BACK OF THIS FORM I >

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3 UNITED PAIN CENTER, A DEPARTMENT OF UNITED HOSPITAL 255 Smith Avenue N. Suite 100 St. Paul, MN New Patient Intake Form Your completed intake paperwork helps our physicians and other providers get to know you and your medical history better. We rely on its accuracy and completeness to provide you with the best possible care. Please inquire at our front desk or call (651) if you have any questions on how to complete any section of this form. Patient Information: Today s Date: Gender: Date of Birth: Name: Referring Physician: Primary Care Physician: Mental Health Provider(s): Pharmacy: Pain History: What is your pain condition? Please list any additional medical conditions? Onset of Symptoms: Approximately, when did this pain begin? What caused your current pain episode? How did your current pain episode begin? Gradually Suddenly Since your pain began, how has it changed? Improved Worsened Stayed the same 1

4 Pain Description: If pain 0 is no pain and 10 is the worst pain you can imagine, how would you rate your pain? Right Now The Best It Gets The Worst It Gets What factors worsen or affect your pain? What factors relieve your pain? Are there any associated symptoms (numbness, tingling, weakness, incontinence, etc)? What is your expectation and goal of your pain management treatment? Diagnostic Testing and Imaging: Check all of the following tests that you have had related to your current pain condition: MRI of the: Date: Facility: X-Ray of the: Date: Facility: CT Scan of the: Date: Facility: EMG/Nerve Conduction Velocity (NCV) study of the: Date: Facility: Other diagnostic testing: I have not had ANY diagnostic tests for my current pain. 2

5 McGill Pain Questionnaire: what does your pain feel like? In each category below, check one word that best describes your current pain. Leave out categories that do not apply to you. On the diagram, shade in areas where you currently experience pain. PROVIDER USE ONLY: PRI: S A E M PRI (T) PPI 1. Flickering Quivering Pulsing Throbbing Beating Pounding 2. Jumping Flashing Shooting 3. Pricking Boring Drilling Stabbing Lancinating 4. Sharp Cutting Lacerating 5. Pinching Pressing Gnawing Cramping Crushing 6. Tugging Pulling Wrenching 7. Hot Burning Scalding Searing 8. Tingling Itchy Smarting Stinging 9. Dull Sore Hurting Aching Heavy 10. Tender Taut Rasping Splitting 11. Tiring Exhausting 12. Sickening Suffocating 13. Fearful Frightful Terrifying 14. Punishing Grueling Cruel Vicious Killing 15. Wretched Blinding 16. Annoying Troublesome Miserable Intense Unbearable 17. Spreading Radiating Penetrating Piercing 18. Tight Numb Drawing Squeezing Tearing 19. Cool Cold Freezing 20. Nagging Nauseating Agonizing Dreadful Torturing PPI 0 No pain 1 Mild 2 Discomforting 3 Distressing 4 Horrible 5 Excruciating Brief Momentary Transient Rhythmic Periodic Intermittent Continuous Steady Constant 3

6 Please Check All Of The Following Treatments You Have Had for Pain Relief: No Change Worsened Pain Helped Pain Spine Surgery Physical Therapy Chiropractic Care Mental Health Therapy Brace Support Acupuncture Hot/Cold Packs Massage Therapy TENS Unit Medical Cannabis Interventional Pain Treatment History: Epidural Steroid Injection (circle levels that apply) Cervical/Thoracic/Lumbar Joint Injection Joint(s) Medial Branch Blocks/Facet Injections (circle levels that apply) Cervical/Thoracic/Lumbar Nerve Blocks Area/Nerve(s) Radiofrequency Nerve Ablation (circle levels that apply) Cervical/Thoracic/Lumbar Intrathecal Pain Pump Spinal Cord Stimulator Trial Only/Permanent Implant Trigger Point Injections Where? Vertebroplasty/Kyphoplasty Level(s)? Other Which of these procedures listed above have helped with your pain? Please list the names of other Pain Physicians you may have seen in the past 4

7 Past Medical History: Please check the following conditions/diseases that you have been treated for in the past: Cancer/Oncology Cancer - Type Cancer - Type Cancer - Type Cardiovascular/Hematologic Anemia Heart Attack Coronary Artery Disease High Blood Pressure Peripheral Vascular Disease Stroke/TIA Bleeding Disorders Heart Valve Disorders Presence of Stent Presence of Pacemaker/Defibrillator Gastrointestinal GERD (Acid Reflux) Gastrointestinal Bleeding Stomach Ulcers IBS/Crohns Disease Urological Chronic Kidney Disease Kidney Stones Urinary Incontinence Dialysis Neurological Multiple Sclerosis Peripheral Neuropathy Seizures Balance Disorder Head Injury Headaches Migraines Stroke ENT Glaucoma Vertigo Hearing Problems Nosebleeds Respiratory Asthma Bronchitis/Pneumonia Emphysema/COPD Musculoskeletal/Rheumatologic Bursitis Carpal Tunnel Syndrome Fibromyalgia Osteoarthritis Osteoporosis Rheumatoid Arthritis Chronic Joint Pain Other Arthritic Conditions Mental Health PTSD Bipolar Disorder ADHD Depression Anxiety Overdose Self Harm Addiction Endocrinology Diabetes - Type Hyperthyroidism Hypothyroidism Other Diagnosed Conditions Please check the following physicians or specialists you have consulted with for your medical care: Acupuncturist Neurosurgeon Mental Health Provider Chiropractor Internist Orthopedic Surgeon Rheumatologist Physical Therapist Neurologist Other 5

8 Past Surgical History: Please list any surgical procedures you have had in the past, including date: 1. Date: Facility: 2. Date: Facility: 3. Date: Facility: 4. Date: Facility: 5. Date: Facility: I have never had any surgical procedures performed. Family History: Please check appropriate diagnoses as they pertain to your parents and siblings: Arthritis Headaches/Migraines Liver problems Seizures Cancer High Blood Pressure Osteoporosis Stroke Diabetes Kidney Problems Rheumatoid Arthritis Other I have no significant family medical history Please use this space to provide any additional information: 6

9 Social History: Occupation: When was the last time you worked? Temporary Disability Permanent Disability Retired Unemployed Are you currently under Worker s Compensation? Is there an ongoing lawsuit related to your visit today? Yes No Yes No Who lives in your current household? Do you use any tobacco products? Yes No If yes, what kind, how much per day? Number of years Do you drink alcohol? Yes No If yes, how much? How often? Do you use recreational drugs? Yes No If yes, which drugs do you use? Do you think you are addicted to the use of alcohol or recreational drugs? Yes No Do you use alcohol or recreational drugs to cope with your pain? Yes No Have you ever been through alcohol or chemical dependency treatment? Yes No Do you have any family members that have abused alcohol or drugs? Yes No (If Yes, who?) Check if you have ever had: Blackouts DWI/DUI Injuries related to chemical use Current Medications: Are you currently taking any blood thinners or anti-coagulants? Yes No If yes, which ones? Aspirin Plavix Coumadin Lovenox Other Please list all medications you are currently taking including, vitamins. Attach additional sheet if needed Medication Name Dose Frequency

10 Please list all previously prescribed pain medications. Attach additional sheet if needed Medication Name Dose Frequency Allergies: Do you have any medication allergies? Yes No If so, please list all medications that you are allergic to. Attach additional sheet if needed. Medication Name Allergic Reaction Topical Allergies: Latex Iodine Medical Tape IV Contrast Mental Health: Have you ever been evaluated or treated by a mental health provider? (for example, a psychologist, counselor, family therapist, psychiatrist) Yes (please describe): No Have you ever been diagnosed and or hospitalized with a mental health condition? (for example, depression, anxiety, panic disorder, substance use disorder, PTSD, ADHD, bipolar disorder): Yes (please describe): No Do you have a history of self-harm? Yes (please describe): No 8

11 Review of Systems: Please check & discuss symptoms you currently have: GENERAL Unintentional wt loss Unintentional wt gain Fevers Chills Night Sweats Excessive Fatigue Insomnia HEAD Headache EYES Vision changes EARS Decreased Hearing Ringing in Ears Earaches NOSE Recurrent nosebleed Sinus infections NECK Stiffness Enlarged gland MOUTH Hoarseness Sore throat CARDIOVASCULAR Chest Pain with Resting Chest Pain with Activity Palpitations Sleep on > 2 pillows Leg Swellings Hypertension Leg Pain with Exercise PULMONARY Shortness of Breath Recurrent Cough Sputum Production Coughing up Blood Asthma/Wheezing Tuberculosis Exposed GASTROINTESTINAL Nausea/Vomiting Diarrhea/constipation Red blood in stool Discuss Discuss Black/Tarry Stool Abdominal Pain Change in Bowel Habit Decreased Appetite GENITOURINARY Painful Urination Blood in Urine Incontinence Discharge STD History MUSCULOSKELETAL Back Pain Joint Pain Joint Swelling Joint Redness Muscle Aches ENDOCRINOLOGY Heat/Cold Intolerance Increased Thirst Change in Hair Pattern SKIN Changes in Moles Rashes HEMATOLOGY Easy Bruising Anemia Abnormal Bleeding Enlarged Lymph Nodes NEUROLOGY Headaches Fainting Dizziness Seizures Numbness/Tingling Blurred Vision Decreased Memory Abnormal Gait Tremor GYNECOLOGY Abnormal Periods Heavy Periods MENTAL HEALTH Depression Anxiety Nervousness 9