ADVANCED PAIN MANAGEMENT
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- Loreen Douglas
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1 ADVANCED PAIN MANAGEMENT Patient Name Date Date of Birth Sex Marital Status Phone Numbers: Home ( ) Work ( ) Cell ( ) Street City State Zip General Health Review Medical History (such as heart disease, stroke, cancer, arthritis, diabetes, hypertension, as well as Psychiatric illnesses, etc.) Surgical History (unrelated to pain; such as appendectomy) Surgical History (related to pain; such as laminectomy) Allergies (include side effects from previous medications, such as gastritis, nausea, constipation, etc.) Intolerances (include side effects from previous medications, such as gastritis, nausea, constipation, etc.) Current Medications (include vitamins and birth control pills, if applicable) 1
2 Do you have any of the following? (Circle all that apply) Headaches Stomach Chest Vision Problems Nausea Shortness of Breath Hearing Problems Vomiting Urinary Problems Dizziness Constipation Rashes Difficulty Swallowing Diarrhea Swollen Joints Chronic Fatigue Domestic Situation With whom do you live? Are there any substance abuse issues in the household? If yes, please explain Any physical abuse issues? Explain: Are you able to take care of yourself? If not, please enter name of caregiver Work History Job Years worked Why did you leave? Legal Matters Are you presently involved in a lawsuit? If yes, please explain. Substance Use Which of the following drugs or substances, if any, have you used in the past? (Circle all that apply) Next to each drug or substance that you ve circled, indicate if you used it occasionally ( O ), frequently ( F ), or continuously ( C ). Alcohol Barbiturates Cocaine Heroin Amphetamines Marijuana Other Other Other (specify) (specify) (specify) Are you presently using any of the drugs or substances below? (Circle all that apply) Next to each drug or substance that you ve circled, indicate if you use it occasionally ( O ), frequently ( F ), or continuously ( C ). Alcohol Barbiturates Cocaine Heroin Amphetamines Marijuana Other Other Other (specify) (specify) (specify) Do you presently smoke cigarettes or use tobacco in any form? If not, did you ever smoke cigarettes or use tobacco in any form? How much packs do (did) you smoke a day? For how many years? 2
3 Reason for visit: History of present illness: Location Quality (How severe is the pain/problem?) (Example normal vs abnormal color, activity, etc.) Severity Duration (How severe is pain on scale of 1-10?) (How long have you had this pain/problem? When did it start?) Timing Context (Does this pain/problem occur at a specific time?) (Where were you at the onset of this pain/problem?) Associated signs/symptoms Modifying factors (What other associated problems are you having?) (What makes the pain/problem worse or better?) Medical History: *Patient Medical History: Diabetes Hypertension Cancer Stroke Heart Trouble Arthritis/Gout Convulsions Bleeding tendency Acute Infections Venereal Diseases Heredity Defects *Patient Social History: Marital Status: Single: Married: Seperated: Divorced: Widowed: Use of Alcohol: Never: Rarely: Moderate: Daily: Use of Tobacco: Never: Previosly quit: Current packs per day: Use of Drugs: Never: Type/Frequency: Excessive Exposure at home/work: Fumes: Dust: Solvents: Air-borne particles: ise: Occupation/Work History: *Family Medical History: Age Diseases If Deceased, Cause of Death Father Mother Siblings Spouse Children 3
4 Review of Systems: Please indicate any personal history: CONSTITUTIONAL SYMPTOMS Good general health lately Recent weight change Decreased appetite Fever/Night sweats Fatigue/Weakness. Headaches. EYES Eye disease or injury. Wear glasses/contact lenses. Blurred or double vision.. Glaucoma/cataracts.. EARS/NOSE/THROAT Hearing loss or ringing Earaches or drainage.. Chronic sinus problems or rhinitis. sebleeds Mouth sores Sore throat or voice change. Swollen glands in neck.. CARDIOVASCULAR Heart trouble Chest pain or angina pectoris. Palpitation.. Shortness of breath w/walking or lying flat Swelling of feet, ankles, or hands. RESPIRATORY Chronic or frequent coughs.. Spitting up blood. Shortness of breath. Asthma or Wheezing.. GASTROINTESTINAL Loss of appetite Change in bowel movement.. Nausea or vomiting. Frequent diarrhea ful bowel movements or constipation... Rectal bleeding or blood in stool.. Abdominal pain Peptic ulcer (stomach or duodenal). GENITOURINARY Frequent urination Burning or painful urination Awaken at night to urinate Blood in urine Change in force or strain when urinating Incontinence or dribbling Sores or discharge Kidney stones Sexual difficulty.. Male testicle pain/lumps.. Female pain with periods Female irregular periods. Female vaginal discharge. Female - # of pregnancies Female - # of miscarriages.. Female date of last pap smear.. Reviewed By: Date: ENDOCRINE Glandular or hormone problem.. Thyroid disease... Diabetes(insulin or noninsulin).. Excessive thirst or urination.. Heat or cold intolerance MUSCULOSKELETAL Joint Joint stiffness or swelling... Weakness of muscle or joints.. Muscle pain or cramps... Back pain.... Difficulty walking.. INTEGUMENTARY (skin, breast) Rash or itching Change in skin color Change in hair or nails... Varicose veins Breast pain Breast lump.. Breast discharge... NEUROLOGICAL Frequent or recurring headaches Lightheaded or dizzy. Convulsions or seizures. Numbness or tingling sensations Tremors. Paralysis Stroke Head injury PSYCHIATRIC Memory loss or confusion Nervousness Depression Insomnia.. HEMATOLOGIC/LYMPHATIC Slow to heal after cuts. Bleeding or bruising tendency Anemia Phlebitis Past transfusion. Enlarged glands ALLERGIC/IMMUNOLOGIC History of skin reaction or other adverse reactions: Penicillin or other antibiotics Morphine, Demerol or other narcotics vocain or other anesthetics. Aspirin or other pain remedies Tetanus antitoxin or other serums Iodine, merthiolates or other antiseptics.. Other drugs/medications: Known food allergies: Environment allergies: 4
5 Primary Care Physician Address City State Zip Phone If Workman s Compensation, list case worker Address City State Zip Phone Would you like letters sent to other physicians? If yes, please list name and address Name Address City State Zip Phone Emergency Contact Relationship Address City State Zip Telephone numbers: (Home) (Work) Initial Assessment By answering the following questions, you will help your physician better understand and treat your pain. When and how did your pain problem start? As far as you know, what is the cause of your pain (ie, the diagnosis)? What doctors have you seen? When did you see them? What did they do? (for example: Doctor did physical exam, Ordered tests, prescribed medication) Doctor s Name Month/Year Seen What Was Done What tests and studies have been done? (for example: MRI, CT-Scan, X-Rays) Month/Year Done 5
6 List the body sites where you experience pain and circle the words that best describe the pain at that site. Also, indicate The intensity of the pain and those things that make your pain better or worse. Use a separate sheet for each body site. Body Site Circle the words that describe you pain. Aching Sharp Penetrating Throbbing Tender Nagging Shooting Burning Numb Stabbing Exhausting Miserable Gnawing Tiring Unbearable Intermittent Continuous Circle the number that best describes your pain at its worst during the last month. Circle the number that best describes your pain at its least during the last month. Circle the number that best describes your pain on average during the last month. Circle the number that best describes your pain as it is right now. What sorts of things make this pain feel better (for example: heat, rest, medicine)? What sorts of things make this pain feel worse (for example: walking, standing, lifting)? 6
7 On the diagram below, shade the areas where you feel pain. X the areas the hurt the most. What pain treatments or medications are you receiving now or have received in the past? (For example, pain medications, physical therapy, acupuncture, TENS, etc.) Circle the number next to the treatment to signify the amount of pain relief that treatment is providing or has provided. Treatment or Complete Check if Medication Relief Relief Receiving w 7
8 Circle the numbers below that best describe how pain has interfered with your daily functioning. General Activity Mood Walking Ability rmal Work Routine Relations With Other People Sleep Enjoyment of Life Ability to Concentrate Appetite Cz0020What level of pain do you think you could function with on a daily basis? 8
9 The attached information was reviewed with the patient by: 9
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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:
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
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Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
Date: Chart # DC # Spouse / Parent / Legal Guardian Details: Name: Relation:
Leader Heights Spine, Joint & Nerve Associates Date: Chart # DC # Patient Information: Please print clearly and complete all sections. Please Circle : Mr. Mrs. Ms. Miss Dr. Rev. Marital Status : Single
Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
NEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Ethnicity: Hispanic Non-Hispanic Mr. Mrs. Ms. Miss Is this your legal name? If not, what is your legal
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
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
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:
1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
MEDICAL HISTORY RECORD
MEDICAL HISTORY RECORD Please print and complete all information. Case. Male Female Medicare. Medicaid. Today s Date Birthdate Last Name First Middle Daytime Phone Home Phone Address City Marital Status
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
Women s and Men s Health Intake Form Comprehensive Physical Therapy Center
Name: (Last, First) DOB: Date: Age: Referring Physician: Next Physician Appointment: Today s visit: What is the main reason you came to the office today? When did it start? What treatments have you had