New Patient Pain Evaluation

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1 New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S = Shooting B = Burning Please answer ALL questions below. Fill in the appropriate bubble. O O O 1. Where is your pain? O Head O Neck O Back O Arms O Legs 2. Using a scale of zero to ten (0-10) how do you rate the severity of your pain on average? (Imagine 0 as pain free and 10 as being the worst pain imaginable.) O 0 O 1 O 2 O 3 O 4 O 5 O 6 O 7 O 8 O 9 O At its worst, how do you rate your pain? O 0 O 1 O 2 O 3 O 4 O 5 O 6 O 7 O 8 O 9 O How do you describe your pain? O Stabbing O Electrical O Aching O Numbing O Dull O Shooting O Burning 5. Does your pain radiate from one spot to another spot? O Yes O No 6. What is the timing of your pain? O Continuous O Intermittent 7. How long does each episode of pain last? O Seconds O Minutes O Hours O All day 8. Was there a known incident that caused the pain? O a fall O surgery O lifting O exercising O car accident O work accident O other accident Date of injury:

2 9. Which of these actions worsens your pain? O standing O sitting O stooping O coughing/ laughing O stress O sex O pulling a load O pushing heavy objects O staying in one position O lying down O riding in a car O changing positions O walking O getting out of bed O repetitive movements O vibrations O cold temperatures O head/neck movements O lifting O hot temperatures O twisting movements O driving 10. Which of these actions helps your pain? O resting O sitting O lying down O standing O walking O massage O ice O heat O traction O stretching O avoiding activity 11. Has your pain affected any of these areas of daily living? O household activities O family activities O recreation & hobbies O appetite O physical exercise O sexual relations 12. Is your pain causing any of these additional symptoms? O bowel accidents O bladder accidents O weakness O difficulty concentrating O sensitivity to light touch O coldness O muscle wasting O muscle spasms O shaking O swelling O skin redness O bluish skin 13. Please mark any treatments you have tried and whether they have helped your pain? Helped Tried but not helpful Helped Acupuncture O O Exercise O O Biofeedback O O Medications O O Chiropractic treatment O O Nerve blocks O O Cortisone - oral O O Physical therapy O O Cortisone injections O O Relaxation/Hypnosis O O Tried but not helpful Epidurals O O TENS O O Other: 14. Are you (or do you think you are) experiencing depression? O No O Yes 15. Have you had any of the following radiology or diagnostic imaging? O X-ray O CT scan O MRI O Nerve conduction/emg Please specify the facility:

3 Do you have any ALLERGIES to medications? O Yes O No Name: Reaction: Please list your current medications: (If you have your medications listed separately, we can make a copy) Medication: Dosage & Directions: Prescribing Doctor: Current and Past Medical Problems: Past Surgeries: O Yes O No Reason: Date: Recent Hospitalizations: O Yes O No Reason: Date: Family History Father Mother Grandparent Sibling Child

4 Social History Marital Status O Single O Married O Partnered O Divorced O Separated O Widowed Dominant Hand O Right O Left Work Status Employed: O Full-Time O Part-Time O Work from Home O Home maker Retired: O Active O Not as active Disabled: O Short-term O Long-term O Permanent Other: O Do you exercise? O Yes O No If "Yes", how often? O 3 times or more per week O 1-2 times per week O < once per week Do you drink alcoholic beverages? Have you ever used illegal drugs? O Yes O No O I suffer from alcoholism If Yes, how often? O 1 per day O 2-5 per day O 6 or more per day O on weekends O occasionally O only at special events O Yes O Never If "Yes", Please specify: O Cocaine O Meth O Marijuana O Ecstasy O Other: Tobacco Use O Yes O Used to but not anymore O Never If Yes, Please specify how much per day: O 1-2 cigarettes O up to ½ pack O 1 pack O more than a pack O dip/chew O unknown Are you trying to quit? O Yes O No Hobbies / Recreational Activities O Yes O No Please specify:

5 Please fill in the bubble next to any symptom you may be currently experiencing: General O Fever O Chills O Fatigue O Weight gain O Weight loss Psychology O Depression O Stress O Memory loss O Anxiety O Suicidal thoughts O Sleep disturbances HEENT O Eye pain O Ear pain O Throat pain O Difficulty hearing O Congestion O Dental problems O Hoarseness Neurology O Headaches O Weakness in arms O Weakness in legs O Seizures O Blurred vision O Sensitivity to light Tingling/Numbness O in arms O in legs O Tremors O Falls O Dizziness Cardiology O Chest pain O Palpitations O Increased blood pressure O Anemia O Swelling of hands or feet Respiratory O Coughing O Wheezing O Shortness of breath O Asthma O COPD O Emphysema O Difficulty breathing Musculoskeletal O Muscle pain O Joint pain O Swollen joints O Morning stiffness O Recent injuries O Broken bones O Arthritis Gastroenterology O Constipation O Diarrhea O Vomiting O Nausea O Bowel accidents O Stool changes O Abdominal pain O Heartburn O Hepatitis Genitourinary O Painful urination O Frequent urination O Bladder accidents O Menstrual problems (females only) O Impotence (males only) O Blood in urine (males only) Hematology/Lymph O Easy bruising O Nose bleeds O Allergies O Frequent illnesses O Bleeding disorder O HIV exposure O Multiple infections O Night sweats Endocrinology O Heat intolerance O Cold intolerance O Hair loss O High blood sugar O Diabetes O Thyroid disorder Dermatology O Hives O Dry or sensitive skin O Rashes O Skin irritation O Atypical moles Patient Signature: Date: