Ohio Valley General Hospital Institute for Pain Diagnostics and Care. 500 Pine Hollow Road 107 Mt. Nebo Pointe Drive
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1 Ohio Valley General Hospital Institute for Pain Diagnostics and Care 500 Pine Hollow Road 107 Mt. Nebo Pointe Drive KenMawr Plaza Mt. Nebo Commons McKees Rocks, PA Pittsburgh, PA INITIAL PAIN ASSESSMENT FORM Patient Name: Date of Birth: Age: Gender: Male Female Social Security Number: Address: Home Phone: Alternative Phone: Person to contact in case of an emergency: Relationship: Phone: EMPLOYMENT INFORMATION: Place of Employment: Address: Phone: Occupation: INSURANCE INFORMATION: Subscriber: Insurance Company: Address: Policy #: Group #: Insurance Phone #: Relationship of patient to subscriber: Subscriber: Insurance Company: Address: Policy #: Group #: Insurance Phone #: Relationship of patient to subscriber: Is this a work-related injury: Yes No If yes, date of the injury: Case worker or contact name: Phone: Is this a motor vehicle-related accident: Yes No If yes, date of accident: Car Insurance: Policy #: Name of Insured: LEGAL ISSUES: Are you currently involved in a lawsuit because of your current pain? Yes No If yes, what is the name of your attorney: Address:
2 Phone: Page 1 Initial Pain Assessment SOCIAL HISTORY: Marital Status: Single Married Separated Divorce Widow(er) Do you feel free from apparent physical or emotional abuse in your home? YES NO If no, would you like to speak to a member from our Social Service Dept.? YES NO Type **Present Use Amount **Past Use Amount Alcohol Cigarettes Cigars Chew/Snuff Marijuana Cocaine Heroine WORK: Occupation: Status: Working FT Same Duties Reduced Duties Working PT due to pain Same Duties Reduced Duties Working PT due to other non-pain related reasons Not working due to pain Not working due to other non-pain related reasons Unemployed seeking employment with reduced duties Unemployed seeking employment without reduced duties Unemployed not seeking employment Retired Homemaker Student : HISTORY OF PRESENT ILLNESS: What is the problem that you are being seen for today? Location: Where is your PRIMARY pain? (consider it to be primary if it is 50% or more of your pain) Please list the amount of time that you have been suffering from this condition in days, weeks, months or years:
3 Page 2 Initial Pain Assessment RATING OF PAIN: Rate your pain level TODAY on a 0-10 Scale? (O no pain, 10 worst imaginable) PAIN DIAGRAHM: On the diagram below, please indicate where you are experiencing pain or other symptoms, right now. A = ACHES B = BURNING P = PINS AND NEEDLES S = STABBING
4 N = NUMBNESS O = OTHER Page 3 Initial Pain Assessment PERSONAL HEALTH HISTORY: Check each of the health conditions you have now or have had in the past. Please enter the approximate date of onset next to each item marked. Items not checked are considered not to be applicable to you. Cardiovascular Pulmonary Musculoskeletal Endocrine Heart attack Asthma Degenerative Arthritis Thyroid Disease Angina or Chest Pain Lung Cancer Rheumatoid Arthritis Diabetes (Insulin Blood Pressure Emphysema Osteoporosis use) Bypass Surgery COPD Falls Diabetes (Oral Angioplasty Chronic Bronchitis Trauma/ AutoAccident Medications) Heart Valve Disease Pulmonary Hypertension Sciatica Diabetes (Diet Pacemaker Recurrent Pneumonia Back Surgery Control only) Defibrillator Implant Sleep Apnea Hip Replacement Heat/Cold Stent Placement in Heart Tuberculosis Knee Replacement Intolerance CHF (Congested Failure) Bloody phlegm/sputum Joint Surgery Hot Flashes Irregular Heart Beat Wheezing Fibromyalgia Excessive Thirst Heart Valve Surgery Cough Myofascial Pain Hypoglycemia (Low Mitral Valve Prolapse Shortness of Breath Chronic Fatigue Syndrome Blood Sugar) Carotid Blockage Neck Pain PVD/PAD Psychosocial Mid Back Pain Genitourinary: Angioplasty to Legs Depression/Mania Low Back Pain Dribbling Abdominal Aortic Stress Shoulder Pain R L Prostate Cancer Aneurysm Anxiety Elbow Pain R L Sexually Bypass Surgery to Legs Nervous Disorder Wrist Pain R L Transmitted disease Stent Placement to Legs Worried Hand Pain R L Kidney Disease High Cholesterol Suicide Thoughts Rib Pain R L Peritoneal Dialysis or Attempts Hip Pain R L Hemodialysis OTHER: Psychological Knee Pain R L Frequent Urinary HIV/ AIDS Evaluations Ankle Pain R L Tract Infections Cataracts Currently Seeing Foot Pain R L LOSS OF BLADDER Retinopathy Psychologist/ Joint Swelling CONTROL Macular Degeneration Psychiatrist Joint/Back Stiffness Blood in Urine Glaucoma Use of Cane/Walker/ Burning with Recurrent Infections Crutch Urination Transplant Surgery: Use of Splints or frequency Cancer: Work related injury Ovarian Cancer Uterian Cancer Gastrointestinal Colitis Hematology/Lymph Neurological General Pancreatitis Anemia Stroke FEVER/CHILLS Irritable Bowel Syndrome Abnormal Bleeding TIA or Mini-Stroke NIGHT SWEATS Abdominal Pain Easy Bruising Seizures Change in Sleep Reflux (GERD)/Indigestion Prior Blood Memory Changes Fatigue Stomach Ulcer Transfusion Numbness/Tingling WEIGHT LOSS/GAIN Hepatitis Swelling in Groin/ Blurred/Double Vision Cirrhosis / Liver Disease Armpit/Neck Lightheadedness Yellow Skin or Eyes Headache Colon Cancer Head and Neck Dizziness/Fainting Skin Nausea/Vomiting Congestion Speech Changes Open Sore Diarrhea/Constipation Nosebleeds Weakness Change in Mole Change in appetite Sore Throat Ringing in Ears Abnormal Color Difficulty Swallowing Hoarseness
5 Unbalanced Walking Rashes LOSS OF BOWEL CONTROL Sores in Mouth or Bloody or Black in Stools Throat For Office Use Only: All other systems negative. Items not checked are negative. Initial Medication/Allergy Sheet Reviewed Signature: MD/PA-C Date: Time: Page 4 Initial Pain Assessment SURGICAL HISTORY: (PLEASE ALL SURGERIES YOU HAVE HAD WITH APPROXIMATE DATES): CURRENT OR PREVIOUSLY TRIED TREATMENTS: PLEASE CHECK ALL THAT APPLY. Name of Treatment OPIOIDS: Darvocet Tylenol #3 Codeine Vicodin Percocet Oxy Contin MS Contin Duragesic Patch Fentanyl Patch Methadone Opana ANTI- DEPRESSANTS Pamelar Elavil Cymbalta Effexor : ANTI- CONVULSANTS Neurontin Lyrica Keppra : MUSCLE RELAXANTS Flexeril Currently Using Have Tried In the Past Name of Treatment NSAIDS: Naprosyn Voltaren Aspirin Celebrex Feldene Ibuprofen Mobic Anaprox Aleve OTHER: Tylenol Ultram Ultracet Oral Steroids PHYSICAL THERAPY TENS UNIT INJECTION THERAPY Epidural Steroid Medial Branch Block Rhizotomy Currently Using Have Tried In the Past
6 Baclofen Skelaxin Zanaflex Sacroiliac Trigger Point Joint Injection Page 5 Initial Pain Assessment NUTRITIONAL SCREENING TOOL: Height: Weight: Current Diet: How do you rate your appetite? Excellent Good Fair Poor Questions Yes No 1. Are there times when you have been unable to obtain food/eat for more than 4 consecutive days? 2. Have you without wanting to, lost 10 lbs. in the past 6 months? 3. Have you without wanting to, gained 10 lbs. in the past 6 months? 4. Does any of the medications that you are currently taking cause you to experience nausea, vomiting, stomach pains, or heart burn? 5. Does any of the medications that you are currently taking cause you to experience constipation or diarrhea? KNOWLEDGE ASSESSMENT: Your Primary Language: Secondary Language: 1. Do you prefer to learn by: Reading Classroom Demonstration Video Repetition 2. Do you have any learning difficulties? Yes No 3. Current living arrangements (check all that apply): House Apartment Assisted Living Personal Care Home/Nursing Home Lives Alone Lives with relative/friend: Stairs 4. Your highest level of education achieved: College graduate High School Graduate : 5. Check below any impairments that pertains to you: Hearing Wears a Hearing Aide Visual Wears Corrective Lens Mobility Requires use of cane, crutches, walker Speech Emotional FAMILY HISTORY: Has anyone in your family every had: Medical Condition Father Mother Grandparent Siblings Cancer Diabetes Heart Problems Circulatory Problems High Blood Pressure Stroke CHECK HERE IF NO SIGNIFICANT FAMILY MEDICAL HISTORY: Completed by: (Patient Signature) Date: Time:
7 For Office Use Only: Reviewed by: M.D./or PA-C Date: Time: R.N. Date: Time: Page 6 Initial Pain Assessment Name of Physician who referred you to the Institute for Pain Diagnostics and Care: Name: Address: Phone: Specialty: Date Last Seen: Name of Your Primary Care Physician: Name: Address: Phone: Specialty: Date Last Seen: Name of any Physicians whom you see regarding your current health to include PAIN TREATMENT (PLEASE INCLUDE NAMES OF ANY PHYSICAL THERAPY OR CHIROPRACTORS USED): Name: Address: Phone: Specialty: Date Last Seen: Name: Address: Phone: Specialty: Date Last Seen: Name of Your Pharmacy: Name/Location: Phone: Patient Authorization Form Consent for Phone Contact In an effort to give you the best possible patient care, it is often necessary to leave a message at your home regarding test results or more often, an upcoming appointment. Please read the following and check all that apply. I prefer all discussions and/or confirmation of appointments be given only to me. If I am unavailable you may leave a message for me to call you back. You may leave test results or confirm appointments with any member of my family. You may leave test results or confirm appointments with a specific person(s):. Name of Person(s) You may leave test results, confirm appointments, and leave messages on my voice mail.
8 Signature of Patient Date Time Page 7 Initial Pain Assessment WP/InitialPainAssessmentRev07/12
PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: Internet: Fax:
PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: 412-221-7640 Internet: www.davidprovenzanomd.com Fax: 412-490-9850 301 Ohio River Boulevard, Suite 203 Edgeworth Medical Commons Sewickley, PA 15143 INITIAL
DOB Age Sex Weight Height Right Handed Left handed
Lee Ann Brown, D.O. Date: Patient Name DOB Age Sex Weight Height Right Handed Left handed Marital Status S M D W Is your problem related to: Car /Bike accident Yes/No Date Slip or Fall accident Yes/No
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
New Patient Information
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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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Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
COMPREHENSIVE REHABILITATION PAIN QUESTIONNAIRE. Date of Visit. Statement of Problem: Date of Injury/onset of condition: Date of birth: Age
5226 Indian River Road, Suite 102, Virginia Beach, VA 23464 COMPREHENSIVE REHABILITATION PAIN QUESTIONNAIRE Please complete and bring to appointment Name Address Home Phone: Date of birth: Age Date of
NEW PATIENT INFORMATION FORM
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Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Email Occupation
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
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Retinal Consultants of San Antonio PATIENT REGISTRATION
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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
Date: DOB: Age: Gender: Right handed: Left handed: Who referred you? Is your problem related to : Job injury Date: Car accident Date: Date: Briefly describe your main problem/complaint. Also, describe
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight:
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Patient Health History
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The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
Providence Neurosurgery PATIENT INFORMATION SHEET
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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
The Rehabilitation Institute Cancer Rehabilitation
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Chayapathy Jollu, MD Board Certified in Physical Medicine and Rehabilitation Patient Initial Pain Questionnaire
Patient Initial Pain Questionnaire Date: Last Name: First Name: Middle Name: Age: Gender: M F Right handed Left handed Referring Physician: Primary Care Physician: Address: Address: Phone: Phone: Fax:
NEW PATIENT VISIT QUESTIONNAIRE
HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Email: Preferred
CENTRAL COAST ORTHOPEDIC MEDICAL GROUP Medical History Questionnaire GENERAL INFORMATION
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PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies: