HPM. Huntsville Pain Management Specialists in Interventional Pain Management James D. Thacker, M.D. NEW PATIENT MEDICAL INFORMATION
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- Evelyn Leonard
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1 NEW PATIENT MEDICAL INFORMATION Patient Name: OTHER CARE PROVIDERS Name Phone Number Referring Provider: Primary Care Physician: Previous Pain Doctors: Spine or Back Surgeon: Anyone else you would like reports and notes to go to: CHIEF COMPLAINT / REASON FOR TODAY S VISIT Describe: PAIN DESCRIPTION Duration (how long have you been experiencing pain? When did the pain start?) Onset of Symptoms: Gradual Work-related Accident Other Describe: Location (where on your body): mostly back / buttocks mostly in legs both (give %) % back % legs mostly neck / shoulders mostly in arms both (give %) % neck % arms Other: Quality(words that describe it): achy stabbing throbbing penetrating shooting cramping cruel torturing burning sharp dull Other: Timing (e.g. constant, intermittent, at night, with activity): Constant Intermittent Only at night With activity Describe: Is it: Worse in the morning? Worse as the day goes on? Same during day? Aggravating Factors (What makes the pain worse?): Sitting Walking Lying down Standing Bending Lifting Alleviating Factors (What makes the pain better?): Ice Heat Lying down Sitting Walking Standing Bending Page 1 / 7
2 SEVERITY / INTENSITY Please rate your pain by circling the number that best describes your pain (0-10 scale; 10= worst pain imaginable.) Right now At its best At its worst PAIN DIAGRAM Please diagram the location and nature of the pain you came to us for. Numbness Pins / Needles Burning Stabbing Aching xxxxx / / / / / ^^^^^ SLEEP Do you have trouble falling asleep? Yes No Do you wake up during the night once you fall asleep? Yes No Do you snore? Yes No I don t know If you snore, your snoring is: slightly louder than breathing as loud as talking louder than talking very loud If you snore, how often do you snore?: Has your snoring ever bothered other people? Yes No Has anyone noticed that you quit breathing during your sleep? How often do you feel tired or fatigued after your sleep? During your waketime, do you feel tired or fatigued after your sleep? Have you ever dozed off or fallen asleep while driving a vehicle? Yes No If yes, how often does this occur? Do you have high blood pressure? Yes No I don t know Page 2 / 7
3 ASSOCIATED SYMPTOMS: PAIN INTENSITY PERSONAL CARE Wasing, Dressing, etc LIFTING WALKING SITTING STANDING SLEEPING SOCIAL LIFE SEX LIFE (If applicable) TRAVELLING I have no pain at the moment The pain is moderate at the moment The pain is very severe at the moment The pain is very mild at the moment The pain is fairly severe at the moment The pain is the worse imaginable at the moment I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but can manage most of my personal care I need help every day in most aspects of self- care. I do not get dressed. Wash with difficulty and stay in bed. I can lift heavy weights without extra pain I can lieft heavy weights but it gives me extra pain Pain prevents me lifting heavy weights off the floor but I can manage if they are conveniently placed (e.g. on a table) Pain prevents me lifting heavy weights but I can manage ilght to medium weights if they are conveniently positioned. I can only lift very light weights I cannot lift or carry anything Pain does not prevent me walking any distance Pain prevents me from walking more than 1 mile Pain prevents me from walking more than 0.5 mile Pain prevents me from walking more than 0.25 mile I can only walk using a stick, a walker, or crutches I am in bed most of the time I can sit as long as I want I can only sit in my favorite as long as I like Pain prevents me from sitting for more than 1 hour Pain prevents me from sitting for more than 30 minutes Pain prevents me from sitting for more than 10 minutes Pain prevents me from sitting at all I can stand as long as I want without extra pain I can stand as long as I want but it gives me extra pain Pain prevents me from standing for more than 1 hour Pain prevents me from standing for more than 30 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain, I have less than 6 hours of sleep Because of pain, I have less than 4 hours of sleep Because of pain, I have less than 2 hours of sleep Pain prevents me from sleeping at all My social life is normal and gives me no extra pain My social life is normal but increases the degree of pain Pain has no significant effect on my social life apart from limiting my more energetic interests (e.g. sports) Pain has restricted my social life and I do not go out as often Pain has restricted my social life to my home I have no social life because of pain My sex life is normal and causes no extra pain My sex life is normal but causes some extra pain My sex life is nearly normal but is very painful My sex life is severely restricted by pain My sex life is nearly absent because of pain Pain prevents any sex life at all I can travel anywhere without pain I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys over two hours Pain restricts me to journeys of less than one hour Pain restricts me to short necessary journeys under 30 minutes Pain prevents me from travelling except to receive treatment Page 3 / 7
4 RADIOLOGY / DIAGNOSTIC TESTS MRI What body area(s) When Where CT Scan What body area(s) When Where X-ray What body area(s) When Where EMG What body area(s) When Where CONSERVATIVE THERAPIES Physical Therapy When Duration Chiropractic When Duration Accupuncture When Duration *Please indicate other therapies tried and elaborate on success of any of these treatments if tried: Massage Rest Exercise Hypnosis Distraction Stress management Behavioral therapy Meditation Yoga Diet / Weight loss Warm compress / Ice PROCEDURES Epidural Body area(s) When Who performed Facets Body area(s) When Who performed Radiofrequency Body area(s) When Who performed Discogram Body area(s) When Who performed Other Pain Procedures SURGERY FOR PAIN Type When Who performed Type When Who performed Page 4 / 7
5 MEDICAL HISTORY List any medical problems you have been diagnosed with or are being treated for: ALLERGIES Check any true allergies you have: No known allergies Iodine Shellfish Latex IVP dye Eggs Penicillin MEDICATIONS Taken currently or in the last month. Please include any supplements or herbal preparations. Med Dosage Frequency Med Dosage Frequency OTHER SURGICAL HISTORY (Non- pain related) Please list your surgical history with approximate dates: Page 5 / 7
6 PSYCHIATRIC HISTORY Yes No Do you have a family history of substance abuse? Do you have a personal history of substance abuse? Do you have a history of preadolescent sexual abuse? Do you have: Attention deficit disorder Bipolar disorder or Schizophrenia Obsessive-comulsive disorder Depression Panic attacks Suicidal thoughts or actions Are you currently seeing a psychiatrist or psychologist? SOCIAL HISTORY Yes No Do you use tobacco products? What How much? packs / per Do you use marijuana? How much? Do you drink alcohol? What How much? drinks / per Do you take any street or recreational drugs? What and how often? Are you involved in any litigation? If yes, attorny name: I am working: Full-time Part-time hours Off work Unemployed Retired / Disabled Occupation: Recreational activities/ hobbies: Have you: Yes No Taken or had injected any steroids in the last 3 months? Ever had any unusual reactions to anesthesia? FEMALE PATIENTS ONLY: Is there any chance you are pregnant? FAMILY HISTORY Page 6 / 7
7 Eyes / Ears (HEENT) Glaucoma Hearing loss / aids Retinal problems Blurry vision Double vision Ringing in ears Change in taste Cardiac (Heart) Hypertension MI (heart attack) CAD (heart disease) Chest pain / angina CHF (heart failure) Atrial fibrilation Valve problem Arrhythmia Pacemaker / Defibrilator Palpiations Respiratory (Lungs) Asthma Bronchitis Emphysema Sleep apnea COPD Shortness of breath Gastro-intestinal Reflus / GERD PUD (ulcer) Irritable bowel Liver disease Pancreatitis Chron s Disease Hepatitis Nausea / Vomiting Genito-urinary Kidney stones Renal failure Incontinence Enlarged prostate Frequent UTI s Hematological Bleeding disorder Luekemia or lymphoma Anemia DVT Pulmonary embolism Endocrine DM (diabetes) Hypothyroid (low) Hyperthryoid (high) Infectious HIV Hepatitis Zoster Infections TB (Tuberculosis) Epstein-Barr Neurologic Seizures Migraines CVA / TIA (stroke / mini-stroke) Incontinence Weakness Musculoskeletal OA (osteoarthritis) RA (rheumatoid arthritis) Osteoporosis Pain in joints Stiffness in joints Fibromyalgia Skin Rashes Itching Swelling Neoplastic (Cancer) Specify: Constitutional Weight loss Fever / Chills Recent weight gain Night sweats Height: Weight: Age: Signature: Date: Page 7 / 7
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New Patient Pain History Form
New Patient Pain History Form Name: Date of Birth: / / Today s Date: / / Date the Pain Began: / / Reason for visit: Describe what caused the pain (accident, injury, etc.): Pain 1. Pain/Symptom Description
Patient Name: Date of Birth:
Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?
INITIAL PAIN EVALUTION QUESTIONNAIRE
INITIAL PAIN EVALUTION QUESTIONNAIRE We are interested in understanding more about your pain. Please help us by filling out this questionnaire. Please bring the completed questionnaire with you for your
Eastern Shore MediCann Clinic, LLC
Eastern Shore MediCann Clinic, LLC New Patient Medical History and Intake Form Medical Marijuana Certification Name Date of Birth Social Security Number Gender: Male Female Address: Street: City: State
SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell
Last Name First Name Middle Name MRN
Dr. Byers Dr. Su Dr. Sponzilli Lisa Elvin, NP Spine Center New Patient Form Last Name First Name Middle Name MRN This form is used to gather information so that my doctor can maximize the time used to
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM First Name MI Last Preferred Name Date of Birth / / Age Gender Patient/Guarantor SS# - - Email Address Martial Status Single Married Other Street Address City State Zip Code Profession
Initial Pain Management Patient Questionnaire
Appt. Date: Appt. Time: Boston Out-Patient Surgical Suites North Tel Fax: 781-407-5892 Initial Pain Management Patient Questionnaire Dear New Pain Management Patient, Welcome to the New England Pain Management
IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED
Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your
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:
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Patient Data Sheet. Emergency Contact Name: Relationship: Contact phone number: Name: Specialty: Office address: Office phone: Fax:
Today s Date: / / Your Information Patient Data Sheet Last ame: First: MI: Sex: M F Date of Birth: / / Age: SS: Address: Home phone: Cell phone: Can we leave message on Home? Y or Cell? Y Are you currently
NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
Personal Information:
Personal Information: Last Name: First Name: Middle Initial: Previous Name(s): Address: City: State: Zip: Date of Birth: / / Social Security: - - Gender: Male Female Home Phone: ( ) - Cell Phone: ( ) -
Beno Kuharich, D.O. Interventional Spine/Pain
Patient Information Today s date: Your name: Date of Birth: Age: Referring Physician: Primary Care Physician: Pain History Chief Complaint (Reason for your visit today)? Does this pain radiate? If so where?