V. Singh, MD C. Piryani, MD K. Liao, MD J. Birgiolas, MD R. Chovatiya, MD PAIN QUESTIONNAIRE. Name: Date of birth: Age:
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1 V. Singh, MD C. Piryani, MD K. Liao, MD J. Birgiolas, MD R. Chovatiya, MD PAIN QUESTIONNAIRE Date: Name: Date of birth: Age: Who referred you to this practice? (newspaper, TV, doctor, friend etc..) Who is your primary care physician: Where is your MAIN pain located? When did the pain start? How did the pain start? Was your pain due to an accident or major trauma (car accident, fall, job related injury, etc.)? If so please explain on last page. FOR NURSE USE ONLY: VITAL SIGNS B/P: HR: RR: T: HEIGHT: WEIGHT: Nurse Comments: Nurse Signature: Date:
2 History of sequence of events: Please list (by date) who you have seen for this problem, list any tests (MRI, CT scan, etc) and treatments (surgeries, medications, physical therapies, chiropractic manipulations, acupuncture, braces, injections, pain programs) you have had related to your pain.
3 Please SHADE IN your painful areas on the diagrams below. PAIN SCALE VAS: No Moderate Worst Pain Pain Possible Pain Using the pain scale above (0 10), please give a number to the pain you experience doing the following things: Resting pain level (sitting, lying down): Daily activity pain level (while walking, standing, dressing, etc.): Strenuous activity pain level: What activity? Average pain level: Using the same pain scale (0-10) what do you feel is an acceptable pain level for you?
4 Do you experience any of these symptoms? Weakness? Numbness? Tingling (pins & needles)? Changes in skin color? Cold skin? Loss of bowel control? Loss of bladder control? Male impotence? Dropping things? Fever? Recent or unexplained weight loss? Explain: Explain: What activities increase your pain? Sitting? Walking? Laying down? Standing? Lifting? Bending backward? Heat? Ice? Weather? Emotions? Work? Sneezing / Coughing? How long? How much?
5 What activities decrease your pain? Sitting? Walking? Laying down? Standing? Lifting? Bending backward? Heat? Ice? Weather? Emotions? Work? Sneezing / Coughing? Alcohol? How much? Do you take medications to decrease your pain Please list? What time of day do you experience the most pain? How often? Occasional/Ep nly at night Please check Yes to those that apply to your pain description. Please be sure to include the location of the type of pain. Burning? Stabbing? Electric shocks? Spasm? Sharp? Aching? Throbbing? Dull? Radiating? Vice like? Location: Location: Other (please describe):
6 Please describe treatments you have tried for your specific pain problem in the past and what effects they have had on your pain: Treatment When Where Improvement Worsened No Change Surgery Medications Physical therapy Chiropractic Brace Acupuncture Injections Pain Program Other Please check the tests you have had for this problem and indicate when and where they were done and of what part of your body: Test Of What When Where X-RAY MRI CAT SCAN MYELOGRAM EMG BONE SCAN DISCOGRAM Other
7 Allergies (Please list allergens and describe what happened.) Allergen Reaction Have you ever had an allergic reaction to: Contrast Dye Describe Reaction: Cortisone/Steroids Describe Reaction: Local anesthetics (Novacaine, Xylocaine) Describe Reaction: Please list your Prescription medications, including Pain medicine and any other (high blood pressure medication, diabetes medications, eye or ear drops, inhalers, etc.) Birth control method (female): MEDICATION DOSE TIMES DAILY PRESCRIBING DOCTOR Please list any other medications you are taking: (Including ASPIRIN, Anti-inflammatory medications such as Advil, Aleve, Tylenol, etc )
8 Are you taking blood thinners? If so, why? Please list any medications that you felt helped your pain: Please list any medications tried that were not helpful: Past Medical History Please check any of the following conditions you have had or presently do have: Diabetes Arthritis Cancer Ulcer Kidney problems Respiratory problems Bleeding problem Infectious disease Seizures (blood thinner, clotting problem) (Hepatitis) High blood pressure Neurogenic disease Stroke Varicose veins Deep vein thrombosis (DVT) Please list any surgeries you have had, including when and where: Surgery type When Where
9 Family History / Illness / Diseases: Mother Father Children Siblings Other Back Problems Diabetes Osteoporosis Arthritis Other (Cancer, Blood circulation Problems, i.e. blood clots) Personal History Do you smoke or use tobacco? (How much) (How long) Do you drink alcohol? Yes No If Yes, how much? Daily Weekly Do you use illegal drugs? Yes No Have you in the past (explain) Do you have a history of prescription drug abuse? Have you had problems with alcohol or drug use? (DUI/loss of job /illness /injury/incarceration) Are you pregnant or planning to become pregnant? Yes No N/A What is your current marital status? Single Living with Partner Married Divorced Widowed What is the highest level of education you ve completed? EMPLOYMENT STATUS: Are you currently working? Yes ( full time part time) No Retired If yes, please describe your occupation including job tasks: Has pain forced you to stop working or limited your capacity at work? Work restrictions: How long have you been off work or restricted at work due to pain? Is this a Worker s Compensation case? Yes No Is there litigation involved? Yes No Do you exercise? Regularly Occasionally Never Why?: How do you sleep? Enough Not enough Interrupted by pain
10 Currently do you have any of the following conditions: Skin: Lumps Dry skin Changes in appearance of texture Changes in color Rashes Sweaty skin Changes to hair or nails Nose/Mouth/Throat: Sores/ulcers Sinus problems Neck pain/stiffness/swelling Voice changes Difficulty or pain swallowing Other Nervous System: Insomnia Depression Nervousness Panic attacks Psychiatric disorder Head trauma Seizures/epilepsy Dizziness/lightheadedness Tremors/shaking Fainting spells Stroke/mini-stroke Chemical dependency: kind Memory loss Other Respiratory System: Shortness of breath Heavy cough Coughing up blood Emphysema/Bronchitis Asthma T.B. (Tuberculosis) Other Vision/Hearing: Decreased vision Cataracts Glaucoma Decreased hearing Ringing in the ears Other Cardiovascular System: Previous heart attack Chest pain Irregular heart beats/palpitations Congestive heart failure Heart valve problems Swelling/edema High blood pressure Bleeding/bruising Blood clots Pacemaker Anemia Poor circulation Rheumatic fever Other Digestive System: Change in bowel habits Heartburn/ulcers Blood in stool Nausea/vomiting Constipation Reproductive System: Pregnant/trying to become pregnant Female organ problems Sexually transmitted diseases Unusual penis or vaginal discharge Impotence/loss of libido
11 Other Liver/Pancreas/Thyroid/Glands: Yellow eyes Diabetes Thyroid disorder Heat intolerance Cold intolerance Swollen glands Hepatitis/liver disorder Excessive thirst or hunger Excessive sweating Other Other Urinary System: Frequent urination Difficulty starting urination Painful urination Urinary retention Blood in urine Kidney stones Women: Urinary stress incontinence Men: Abnormal prostate condition Other General: Joints: Fever Arthritis (where) Chills Stiffness (where) Night sweats Swelling (where) Severe fatigue Other Generalized weakness Loss of Appetite Undesired weight loss Tumor/Cancer HIV/AIDS Tick bite reaction Recent cold or other illness Increased appetite Undesired weight gain Other
12 I hereby confirm that all the above information is true to the best of my knowledge. I give consent to history taking and physical examination by Spine Pain Diagnostics Associates physicians and their designees. (Signature of patient OR legal representative) Person assisting with filing out this questionnaire Comments: If your pain is a result of an injury? If so please explain what happened: Date of injury: Motor vehicle accident? Yes No Work related? Yes No Are you in litigation? Yes No Mechanism of injury (What happened: If car accident, how fast, where were you sitting, where you belted in, was there damage to the car, etc ) Did you have pain immediately? Yes No Did you seek treatment immediately? Yes No Where/What? What type of treatments have you had for this pain? Where? What? If a police report was filed please attach copy and any other records pertinent to this case Signature
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Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
PLEASE DESCRIBE YOUR PRIMARY HEALTH CONCERNS
Dr. Kenzie Maloy, DC, DABCI, DACCP, DACBN 505 E. Main St. Suite B Hermiston, OR 97838 Phone:541-371-3700 Fax:541-515-7022 PERSONAL INFORMATION: First Name: Last Name: Middle Initial: Email for doctor communications:
Welcome to About Women by Women
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AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM
PATIENT MEDICAL HISTORY FORM Name: Date: Social Security #: DOB: Height: Weight: Email: Primary Care Physician: Referred by: Pharmacy Name/Location/Phone Number: Dialysis Center and Phone Number (if applicable):
MICHIGAN INTERVENTIONAL PAIN ASSOCIATES
MICHIGAN INTERVENTIONAL PAIN ASSOCIATES Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and REPORTS of any X- rays, MRI or
Spine New Patient Questionnaire Rev
Spine New Patient Questionnaire Rev 10.13.10 Name: Male Female Temp: Height: Weight: Date of Visit: Date of Birth: Age Today: *Please note this is a multi-part questionnaire. When you are done, please
Placer Private Physicians: Patient Health Questionnaire [2]
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Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Phone ( ) Age Birth Date Sex S.S.N. Employer Address Did you report this to YOUR Car Insurance? Yes No (Circle One) Your Car Insurance Co. is Claim # Claims Adjuster
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
Other doctors to receive copies of records : Chief complaint / history of present illness (Describe why you have been referred here):
Patient Name: Date: Age: Date of Birth: Preferred Name: Preferred Language: Address: City: State: Zip: Phone: Cell Phone: Preferred Phone: Emergency Contact: Relationship: Email: If you would like to opt
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