The UW Pain Treatment and Research Center takes a holistic approach to your pain care.
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1 Pain Treatment and Research Center 5249 East Terrace Drive Madison, WI Phone: (608) Dear Patient: The UW Pain Treatment and Research Center takes a holistic approach to your pain care. You will be meeting with a physician, physical therapist, and pain psychologist. Your appointment is on In addition, please read and sign the Agreement for Psychological Treatment, which is a standard form required prior to meeting individually with you. Please complete the enclosed questionnaire for your meeting with the psychologist. The psychologist will gather information on how your pain condition has affected your life. The psychologist will evaluate how stress and other lifestyle factors add to your pain discomfort and offer suggestions to help you cope better. We realize that you may have been asked the same information on other UW Pain clinic forms. We appreciate your cooperation in providing the information asked of you on this form as well. Please bring the completed form to the appointment and hand it directly to the psychologist. If you have questions about this form, please contact an administrative assistant Sincerely, Shilagh A. Mirgain, Ph.D. Licensed Psychologist Norann Richard, Ph.D. Licensed Psychologist If you would like to learn more about health psychology and the treatment of chronic pain prior to your intake appointment, please view the following videos on UW website: and/or videos about our pain management and coping groups at: (panels 3 6).
2 UW Pain Treatment and Research Center Name: Today s Date: Gender: Age: Date of Birth: Who referred you to the health psychologist? PAIN and/or HEADACHE DESCRIPTION 1. WHERE is your pain? (example: lower back, neck, headache) 2. WHEN did your pain start? (month and year) 3. HOW did your pain start? (check all that apply) Following a work related injury (Date: ) Following an automobile accident (Date: ) Following a fall Following a physical assault Following a surgery I have always had pain. I don t know why I have pain. I have a medical condition that causes my pain (see next question) 4. WHAT medical diagnosis do you have that is causing your pain? (choices continues on next page) Arthritis Bulging disk Carpal Tunnel Cluster headaches Daily Tension Headaches Migraine headaches Complex Regional Pain Syndrome (RSD) Degenerative disk disease Degenerative joint disease Herniated or bulging disk Fibromyalgia
3 Torn rotator cuff Other 5. Have you ever had BACK, SHOULDER, or KNEE SURGERY for your pain condition? (If yes, what kind of surgery and when?) 6. Please check the words that best describe your pain. Aching Burning Cramping Exhausting Frightening Gnawing Heavy Hot Numbing Pounding Throbbing Sharp Shooting Splitting Stabbing Tender Other 7. How would you rate the INTENSITY of your pain TODAY? No pain Moderate Pain Severe Pain
4 8. What is the LEAST or BEST your pain has gotten over the past 2 weeks? No pain Moderate Pain Severe Pain 9. What is the WORSE or MOST INTENSE your pain has gotten over the past 2 weeks? No pain Moderate Pain Severe Pain 10. WHEN does your pain occur? (Check all that apply. -items continue on the next page) Constantly ( 24 hours per day) Intermittently (off and on depending on the day) When I cough or sneeze When I move my bowels When I urinate or pee When I m bending When I m standing When I am at work When I am tense or anxious When I think about it When I m lifting something When I am walking When I am sitting When I am resting When I am lying down When I do mild exercise When I am tired When I am stressed When I am doing any physical activity
5 When I am nervous or anxious When I am down or depressed When the weather is cold or damp When the weather is hot or humid 11. WHAT kind of TREATMENTS have you tried for your pain? (Check all that apply.) Acupuncture Acupressure Biofeedback Therapy Chiropractic care Cortisone Injection Dietary changes Epidural injection Facet injection Hypnosis Massage Occupational Therapy Pain Medication (pills you take by mouth) Pain Block injections Physical Therapy Radial frequency procedure Spinal Injections Surgery TENS unit Ultrasound Water therapy Others: 12. WHAT helps Lessen or Relieve your pain (even if it is temporary)? (Items continue on the next page) Cold application Changing positions Exercise or stretching Distracting my attention away from the pain Heat application
6 Journaling Laying in bed Listening to music Listening to relaxation tapes Pacing my physical activities Pain medication Massage Meditation Reading Rest Sitting in a dark quiet room Taking a warm shower Talking to my family and friend TENS Unit Other: 13. What do you think is causing your pain? 14. DO you experience HEADACHES? Yes NO (If NO then skip to the next section Medical History, question #21) 15. HOW long have you been experiencing headaches? years months 16. HOW often you get headaches? Every day 4-6 times per week 2-3 times per week Less than 15 times per month More than 15 times per month 1 time per month a few times per year
7 17. WHERE do you feel your headache pain? All over your head Back of the head Forehead Temples One side of the head (which side? ) 18. HOW long do your headaches last? Several hours An hour or less A full day Several days Constant 19. Do your HEADACHES have any of the following FEATURES? Blurred vision before the start of the headache Nausea Pain worse on one side of the head Pain worsens with physical activity Sensitivity to light Sensitivity to noise Vomiting 20. WHAT medications do you take for headache? 21. BESIDES MEDICATION, do you do anything else to relieve your headache? (such as relaxation, cold compress, self-massage)
8 MEDICAL HISTORY 22. Do you have any of the following conditions? Arthritis Asthma Aneurysm Bleeding Disorder Crohn s Disease Fibromyalgia Irritable Bowel Syndrome Cancer Diabetes Heart Problems Heart Attack High Blood Pressure GI (stomach indigestion) Problems Seizure Disorder Stroke Thyroid Problems Kidney Problems Other: 23. Does anyone in your family have problems with pain or headache? (If yes, please explain)
9 24. What other medical or psychological problems run in your family? 25. What MEDICATIONS are you prescribed? Please include any vitamins or herbs you are taking. Medication Dosage Reason Prescribing Physician
10 26. Please list your ALLERGIES to MEDICINES or FOODS. 27. Please list any other major SURGERY you have had and when? PERSONAL HISTORY 28. Are you: Single (never married) Married Partnered (same-sex partner) Widowed Divorced Separated In a relationship 29. Who do you live with? 30. How many Children do you have? 31. What are the ages and genders of your children? 32. Are you currently working? Yes No
11 33. If you are working, what do you do? 34. Are you receiving Social Security Disability? Yes, SINCE WHEN? No 35. How far did you go in school? Less than high school High school diploma or GED Some College College degree Graduate degree OTHER HEALTH QUESTIONS 36. Have you ever had problems with anxiety, panic attacks or depression in the past? (If yes, please describe)
12 37. What outpatient services have you received for any emotional or psychiatric problem such as anxiety or depression? Service means receiving counseling or medication by a physician, psychiatrist, psychologist, social worker, or counselor. If yes, please provide the name of the health professional and time period you saw the professional. 38. Are you currently seeing a psychiatrist, psychologist, social worker, or other type of counselor? If yes, who? Please provide an address and phone number. 39. Have you ever been hospitalized for a psychiatric reason? (continued on next page) Hospitalization means being admitted to the psychiatric unit of a hospital to receive mental health services? If yes, please describe the situation briefly.
13 40. Have you received treatment for a drug or alcohol problem in the past? (If yes, for what drug, when and where?) 41. Has anyone ever told you that you had a problem with alcohol or drugs? Yes No 42. How often do you consume alcohol? 43. Please check all the drugs you are CURRENTLY using. Marijuana (weed) Cocaine Heroin Speed Crack Injection drugs Ecstasy ( Vitamin E ) Other I am not using any drugs 44. Please check any drugs you used in the PAST. (continued on next page) Marijuana (weed) Cocaine Heroin Speed
14 Crack Injection drug use Ecstasy ( Vitamin E ) Other I never used drugs. 45. Do you smoke cigarettes? Yes No If yes, how many cigarettes or packs per day are you smoking? 46. How much caffeine do you consume per day (such as coffee, soda)? 47. On average, how many hours of sleep are you getting a night? 48. How often do you exercise per week (PT exercises, walking, etc)? times, for minutes. Types of exercise you do regularly: 49. Is there any additional information you think would be helpful for us to know? PLEASE BRING THIS FORM WITH YOU WHEN YOU SEE THE PSYCHOLOGIST. You will not be able to be seen without having this form complete.
The UW Pain Treatment and Research Center takes a holistic approach to your pain care. Your appointment is on with.
Pain Management Clinic 1102 S. Park Street, 3 rd Floor Madison, WI 53715 Phone: (608) 263-9550 Dear Patient: The UW Pain Treatment and Research Center takes a holistic approach to your pain care. Your
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