COMPREHENSIVE REHABILITATION PAIN QUESTIONNAIRE. Date of Visit. Statement of Problem: Date of Injury/onset of condition: Date of birth: Age
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1 5226 Indian River Road, Suite 102, Virginia Beach, VA COMPREHENSIVE REHABILITATION PAIN QUESTIONNAIRE Please complete and bring to appointment Name Address Home Phone: Date of birth: Age Date of Visit Referred by Statement of Problem: Date of Injury/onset of condition: SSN Circumstances of injury/onset: Location at time of injury/onset: Time of event: What increases your symptoms? (Mark each one that applies) sitting standing walking bending lifting twisting stooping coughing sneezing reclining reaching gripping driving pinching squatting climbing Other (please list) What time of day is your pain worst? What time of day is your pain least? What percentage of your pain is arm or leg pain? What percentage of your pain is neck or back pain? What decreases your symptoms? Please list 3 goals you would like to achieve as a result of medical treatment. Which daily activities are affected by your current pain condition?
2 Pain Diagram Mark the areas on your body where you feel your pain. Include all affected areas. Use the appropriate symbols indicated below. Ache >>> Numbness === Pins&Needles... Burning XXX Stabbing / / / >>> ===... XXX / / / >>> ===... XXX / / / Is your pain constant? Yes / No If yes, has it been constant for the last year? Yes / No If no, how many days per week do you have pain? How many hours per day? Please place an X on the line below to indicate the level of your pain. Today: None severe / worst imaginable Least: None severe / worst imaginable Worst: None severe / worst imaginable How would you describe the overall severity of your pain? Mild nuisance pain Mild to moderate, but I can live with it. Moderate I am having difficulty dealing with it. Severe it is ruining my quality of life
3 Have you ever been to a pain management clinic in the past for your complaint? Yes / No If yes, when where and who was your physician? Please circle all of the previous medications that you have tried: Medication Discontinued Reason Discontinued Reason Ibuprofen Cymbalta Naprosyn Effexor Aspirin Lexapro Tylenol Zoloft Celebrex Paxil Bextra Prozac Mobic Lidoderm Patch Arthrotec Ultram/Ultracet/Ultram ER Relafen Tylenol #3/Tylenol #4 Skelaxin Darvocet/Darvon Flexeril Percocet/Percodan Soma Lortab/Lorcet/Vicodin/Vicoprofen Zanaflex Morphine Robaxin Dilaudid Valium Duragesic Patch Xanax Oxycontin Neurontin Demerol Tegretol Actiq _ Zonegran Fentora Lyrica Opana Elavil MS Contin Pamelor Kadian Avinza MSIR Oramorph Voltaren gel Wellbutrin Flector Patches Please circle all of the previous treatments: Treatment/Procedure Limited Relief Lasting Relief
4 PT/OT Yes / No Yes / No Orthotic Device Yes / No Yes / No TENS Unit Yes / No Yes / No Osteopathic Manipulation Yes / No Yes / No Epidural Injection Yes / No Yes / No Facet Block Yes / No Yes / No Nerve Block Yes / No Yes / No Sacroiliac Joint Injection Yes / No Yes / No Trigger Point Injection Yes / No Yes / No Joint Injection Yes / No Yes / No Acupuncture Yes / No Yes / No Chiropractor Yes / No Yes / No Stimulator/Pump Yes / No Yes / No Massage Therapy Yes/ No Yes/ No Personal / Medical History Do you have a primary care provider (family physician)? Yes / No If yes, who? List past and current medical and/or psychological problems (please describe and give approximate dates of onset, use a separate sheet if necessary). Surgeries:
5 Current Medications (please list) MEDICATION REASON DOSE FREQUENCY Please list any other medications on a separate sheet. Medication allergies: Please tell us about yourself What is your highest level of education completed? : Are you: Single Married Separated Divorced Widowed Do you have children? Yes / No If yes, how old are they? _ What is your occupation? Employer: Do you use tobacco? Yes / No If yes, do you smoke cigarettes? How many per day? How many years? Do you smoke cigars or a pipe? How many per day? How many years? Do you chew tobacco? How many cans per week? How many years? Are you a former smoker / tobacco user? Yes / No If yes, at what age did you quit? Do you use alcohol? Yes / No If yes, how many alcoholic beverages do you drink in a usual week? If no, have you ever used alcohol? Yes / No Do you currently use recreational drugs? Yes / No If yes, what type and how much? Have you had abuse problems with recreational drugs in the past? Yes / No If yes, please describe: Have you had abuse problems with prescription medications in the past? Yes / No If yes, please describe: Are the any recreational drug problems or problems with prescription medications in your household at the present time? If yes, please describe: Please circle the appropriate diseases with regards to your family history: Mother High Blood Pressure Diabetes Heart Disease Cancer Arthritis Stroke Heart Attack Father High Blood Pressure Diabetes Heart Disease Cancer Arthritis Stroke Heart Attack Siblings High Blood Pressure Diabetes Heart Disease Cancer Arthritis Stroke Heart Attack Sons/Daughters High Blood Pressure Diabetes Heart Disease Cancer Arthritis Stroke Heart Attack Aunts/Uncles High Blood Pressure Diabetes Heart Disease Cancer Arthritis Stroke Heart Attack Grandparents High Blood Pressure Diabetes Heart Disease Cancer Arthritis Stroke Heart Attack
6 Please circle any problems that you have from the list below: Abdomen Ear/Nose/Throat Past Medical History Vomiting Ringing in Ears Diarrhea Loss of hearing Depression Constipation Nose Bleeds Chicken Pox Bloody Stools Sore Throat Arthritis Heartburn Hoarseness Mumps/Measles Cancer Genitourinary Neurological Hepatitis Pain with urination Fainting spells Skin Disease Inability to urinate Weakness Polio Incontinence Dizziness AIDS/HIV Bloody urination Headaches Epilepsy Decreased desire for sex Tremors Blood Transfusion Infectious Mono Psychiatric Endocrine STD Anxiety Weight gain Depression Weight loss Memory Loss Excessive Thirst Suicidal Ideation Cold Intolerance Inability to sleep Heat Intolerance Thyroid Disease General Fever Chills Fatigue Sweats Lungs Cough Shortness of Breath Cough up blood Sleep Apnea Heart Chest pain Irregular Heart beat Heart Murmur Eyes Blurry Vision Double Vision Irritation Discharge Skin Rashes Coldness of hands/feet Dry Skin Easy Bruising Musculoskeletal Joint pain Joint swelling Muscle Cramps Are you currently pregnant or may be pregnant? Please circle your daily activities on a typical day. Walking: greater than 20mins or less than 20mins. Drive Cook/Dishes Vacuuming, mopping, sweeping floors Dress Children/Spouse Stairs: Go up/down at least one flight of steps unassisted. Grocery shop unassisted/put away groceries Laundry Dress Self Bathe unassisted
DOB Age Sex Weight Height Right Handed Left handed
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Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
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Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain 0 = Numbness / = Aching * = Pins & Needles
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1275 Olentangy River Rd. Ste 120 Columbus, Ohio 43212 Telephone (614) 291-5555 Fax: (614) 291-7720 Dr. David B. Kaplansky Dr. Randall Contento PATIENT Dr. INFORMATION Garrett Kalmar FORM www.columbusohiopodiatrist.com
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
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
NEW PATIENTS' INFORMATION SHEET
NEW PATIENTS' INFORMATION SHEET Please print clearly. Please complete all information so that your claim can be processed quickly and efficiently. Thank you! PATIENT INFORMATION (First) (MI) (Last) Name
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form
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
Samuel A. Joseph, Jr., M.D. In order to be seen by one of our physicians, you must bring the following to your visit:
Samuel A. Joseph, Jr., M.D. Your appointment has been scheduled: Your appointment time is: Please arrive at: o o o 2727 West Dr. Martin Luther King Jr. Blvd. Suite 590 Tampa, FL 33607 1840 Mease Drive
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM
Name: MR#: Date: DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM Referring Physician s Name: Primary Care Provider s Name: 1. What was/were your first movement disorder symptoms? What did you