New Patient Questionnaire/Assessment
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- Eustacia Wilkins
- 5 years ago
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1 Welcome to the St. Joseph Mercy Pain Institute. Your answers to the following questions are important for your evaluation and care. Please read each question carefully and answer all 4 pages as completely as possible. Name: Date: Address: City State Zip Phone #: Age: Birthdate: / / Height Weight Name of Medical Insurance Are services related to Worker s Compensation claim? No Yes Please provide name of designated person that is your patient advocate or who can provide information regarding your Durable Power of Attorney for health care: Please list the names of people who should receive information about your visit: Primary Physician: Name Address: City State Zip Referring Physician: Name Address: City State Zip Others: ST. JOSEPH MERCY ANN ARBOR ST. JOSEPH MERCY LIVINGSTON ST. JOSEPH MERCY SALINE ST. JOSEPH MERCY BRIGHTON St. Joseph Mercy Pain Institute New Patient Questionnaire/Assessment Name Address: City State Zip Check any symptoms you may be experiencing burning cold/hot tingling cramping pounding sharp/dull pressure shooting squeezing throbbing intermittent constant aching spasms numbness weakness Describe in your own words what it feels like Do you notice any of the following physical changes with your pain? hair growth loss of consciousness paralysis nail beds or skin color/temperature loss of bowel or bladder control sweating vision muscle spasms swelling R 10/08 (PC) D Page 1 R L L R Please show the location of your pain by shading the picture
2 When did your pain start? What initially caused your pain? Does your pain occur? hourly daily weekly occasionally constantly Has your pain changed over time? No Yes If yes, describe What relieves your pain? What makes your pain worse? What medicines have you tried for pain relief? Please check all of the following that apply: missing work because of pain involved in a lawsuit Do you use alcohol Are you sexually active workman s compensation case Do you use drugs Under psychiatric care Do you have children Y N receiving disability Do you smoke Married how many Family History Depression No Yes If yes, describe Chronic Pain No Yes If yes, describe Within the last year have you been hit, slapped, kicked, choked, or otherwise physically hurt by someone? No Yes If yes, describe Within the last year, have you been forced to have sexual contact when you did not want to? No Yes If yes, describe Are you on a special diet? No Yes Unintentional significant weight loss? No Yes Have you ever had difficulties with spinal, epidural or local anesthetics? No Yes If yes, please explain Please list when and where you had the following procedures: X-rays CAT MRI Scan Bone Scan Myelogram EMG Please list when and where you were treated by any of the following specialists for your current pain problem: Pain Clinic Physical Medicine/Rehab Neurosurgeon Orthopedic Surgery Neurologists Internist/Family Doctor Emergency Room Psychiatrist/Psychologist Physical Therapy/TENS UNIT Chiropractor Acupuncture WHERE DATE(S) Are you or could you be pregnant at this time? No Yes Please notify the physician of any infectious disease history. Is there anything else that we should know that would assist us in treating your pain? Page 2
3 For the following questions with a scale of 0-10 please circle one number only 1. How would you rate your pain on a 0-10 scale at the present time, that is right now, when 0 is no pain and 10 is worst pain? 2. In the past six months, how intense was your worst pain rated on a 0-10 scale, when 0 is no pain and 10 is worst pain? 3. In the past six months, on average, how intense was your pain rated on a 0-10 scale, when 0 is no pain and 10 is worst pain? 4. About how many days in the last six months have you been kept from your usual activities (work, school or housework) because of this pain 0-6 days 7-14 days days 31 or more days 5. In the past six months, how much has this pain interfered with your daily activities rated on a 0-10 scale, when 0 is no interference and 10 is unable to carry on activities? No interference Unable to carry on activities 6. In the past six months, how much has this pain changed your ability to take part in recreational, social and family activities when 0 is no change and 10 is extreme change? No change Extreme change 7. In the past six months, how much has this pain changed your ability to work (including housework) when 0 is no change and 10 is extreme change? No change Extreme change 8. What is your individual pain management goal? pain activity. Page 3
4 Please note all of the medical conditions below and circle all that may apply: General Health Ear, Nose, Throat Heart Lung Intestinal Hormonal Lymph nodes Muscles/Bones Skin Brain Sleep or psychological Blood Disorders Kidney Eyes Neck/spine Liver Fever, weight loss, cancer history Cold symptoms, sinus infections, thrush (white film in mouth) High blood pressure, chest pain, poor circulation, heart failure, valve disease, blood clots Cough, asthma, emphysema, chronic bronchitis, shortness of breath Nausea, vomiting, bleeding ulcers, constipation, reflux, heartburn, diarrhea, loss of bowel control Diabetes, change in blood sugar control, thyroid disorder, calcium imbalance Enlarged lymph nodes in neck, arm pits, or groin areas Osteoarthritis, bone density, lupus, rheumatoid arthritis Rash, infection, blisters Seizures, paralysis, strokes, TIA s facial drooping, slurred speech Insomina, excessive tiredness, anxious, depression Bleeding problems, excessive bleeding when cut, easy bruising Urinary tract infections, kidney pain, blood in urine, loss of bladder control Glaucoma, cataracts, mascular degeneration Arthritis, scoliosis, surgery Hepatitis, cirrhosis, jaundice Please list all of your surgeries and when they were performed: Page 4
5 Medication Summary List Patient Name: MRN #: DOB: Are you on any of the following medicines? G Lovenox (enoxaprin) G Coumadin (Warfarin) G Plavix (clopidogrel) G Aggrenox (Dipyrideamole) G Ticlid (ticlopidine) Current Medications, Vitamins, Herbal and Nutritional Supplements: Date initiated Date Discontinued ST. JOSEPH MERCY ANN ARBOR ST. JOSEPH MERCY LIVINGSTON ST. JOSEPH MERCY SALINE ST. JOSEPH MERCY BRIGHTON St. Joseph Mercy Pain Institute Drug Name Dose Frequency Allergies: Physician who ordered DO NOT WRITE BELOW THIS LINE Date list updated Staff Date list updated Staff Date list updated Staff Date list updated Staff Page 5
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WELCOME to the Florence Chiropractic and Wellness Center.
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Personal Health Risk Appraisal
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