Pain Questionnaire. Family name:... First name:... Address:...
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- Alexina Davis
- 5 years ago
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1 I see a complete universe in every single human being (Dr. Still, Founder of ostepathy) Pain Questionnaire Family name:... First name:... Address:. ZIP:... City:... Phone.:... Mobile:... Insurance no.:... Insurance co.:... Date of Birth.:... Sex: F M Employment:... Employer: Marital Status: Where do you feel pain? 2. I don t suffer from pain, i have troubles with: Troubles Since when remarks 3. What do you think your pain/ troubles have its seeds in? 4. Can you see a connection with anything? 5. Is your pain radiating to other areas? If yes, where does it start and to where does it lead?...
2 6. How would you describe your pain? (please circle the following) Pulling/ pinching/ stabbing/ tingling/ cramping/ dull/ burning/ knifelike/ throbbing/ biting/ continuous Any other description? On the scale below, please markt he pain intensity: (0=no pain 10=worst pain) In the sketch below, please mark origins and ways of the pain: 9. How often do you feel pain? 10. Please characterize the pain Sudden pain attacks/ continuous pain 11. How long do the episodes last? 12. Since when do you feel this pain? 13. Has the pain increased recently? 14. If yes, since when? 15. During what time of day do you feel the worst pain? Daytime/nighttime
3 16. Is the pain triggered or increased by activity of by any other circumstances? If yes, by which? Does the pain increase when keeping certain positions/postures ( sitting or standing, for a long time)? 18. Do you exercise any sport regularly? If yes, which one? What kind of hobbies do you have (regularly)? 20. Does anybody else in your family suffer from pain episodes? 21. Is the pain intensity influenced by weather? 22. Did you have any important surgerys? When? Surgery When Remarks 23. Did you have any accidents? (Please name all accidents you had)? Accident When Remarks
4 24. Do or did you have any diseases at following organs? Organ Yes No Remarks Heart Brain Lungs Thyroid gland Joints Gastrointestinal tract Liver Kidney Other 25. Did or do you have any of the following diseases? Yes No Remarks Diseases Rheumatism Diabetes High blood pressure Mind Infectios diseases Other 26. Do you believe that your pain was triggered by a specific event? (eg. Disease, surgery, accident, stressful life, event, pregnancy, etc.) 27. Do you smoke? Never I did smoke, i stopped... Yes. Since when? How much?... I would like to quit
5 28. How well do you sleep? Very well/ problems falling asleep/ problems staying asleep/ the pain keeps waking me up 29. Which medication do you take/ for how long/ which dosage? Medication How often? For how long? 30. Which medication on your list have you tolerated well? 31. Which medication on your list have you not tolerated well? Which adverse reactions do you experience? (please explain shortly)? 32. Do you have any food and/or drug allergies? 33. How do you treat your pain? Not at all/ with medication/ with warm temperatures/ with cold temperatures/ with physical activity/ by pressing the pain source/ with relaxation/ by keeping a certain position/ any different ways? Are you currently receiving pension money or will you do so in the near future? If yes, for how long? For how long has your pain kept you off your job and / or from performing every day life activities? Which doctors, hospitals, ambulaces or institutes have you consulted for pain treatment until now? (eg. General practitioner, orthopedist, chiropractitioner, )
6 37. Which forms and methods of treatment were tried? Did they increase, decrease or eliminate the pain? Treatment/Method/Operation Increased Decreased Eliminate 38. For women: (optional) Questions to your health: Questions Yes No Remarks Do you take a birth control pill? Is you menstrual period regulary? Do you suffer from pain in your abdomen during your menstrual period? Do you suffer pain in your back during your menstrual period? Are you bad-humoured during this time? Are you pregnant? Did you have any pregnancies? If yes, how many? How was your pregnancy for you? How often did you give birth? Did you have any C-sections? If yes, how many? How did you experience the births of your children? Did you have any complications
7 during the childbirth? Other remarks: 39. Is there anything you`d like to ask/ Additional remarks: How did you find us? Friends / Family/ Homepage/ Internet Other: How do you imagine your treatment in our center? How can we help you? After filling in this form, please take it with you at you firt appointment, fax, or mail it to us. Fax: 01/ , office@stz.at If you can t make it, please inform us 24hours before your appointment. Patient signature: Humans are so much more than a sum of their parts. They are a unity out of body, soul and spirit! (OA Dr. Selim MSc, neurologist & osteopath, 2016) You start a life free of pain here and now. (OA Dr. Selim MSc, neurologist & osteopath, 2016)
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PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:
Practice: Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters, reminders, statements, etc. Address: City: State:
It's your life... be there healthy. RIGHT LEFT RIGHT
Dr. Sara Weigel Dr. Douglas Ness Active Life It's your life... be there healthy. Chiropractic Patient Information Major Complaint Information Date First Name: Last Name: Initial What is your major complaint(s)?
Byers Wellness Center- Patient Information for HCG Program. General Patient Information
1 Byers Wellness Center- Patient Information for HCG Program Welcome to Byers Wellness Center. We are excited to have you as one of our patients. In order for us to best serve you on your initial visit
Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address: