PM&R Health History. Name: Social Security Number: Date of Birth: Address: State: Zip Code: Age:

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Marilyn Baker
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1 PM&R Health History Name: Social Security Number: Date of Birth: Address: State: Zip Code: Age: Referring Physician: Chief Complaint: Describe when and how present problem began: (if this injury is related to Worker s Compensation or No Fault please notify receptionist) Describe previous treatment, if any, for present problem: List tests (i.e., x-rays, MRI, CT Scan) for present problem, include where and when preformed: 4. List activities you are having trouble performing due to present problem: 5. Describe the pain you are experiencing: Pain is (check one) Constant Intermittent Describe what decreases pain: Describe what increases pain: Please rate pain over the past 30 days: No Pain=0 Maximum Pain= List surgical history: Pain now Best Day Worst Day 7. List medications you are taking: 8. State your occupation: Currently working (check one)? Yes No If working fill in: Hours/Day Days/Week 9. Are you presently being treated by a chiropractor (check one)? Yes No

2 Check the conditions which apply to the patient, or the patient s family. Please fill out this questionnaire as best as possible. (If you don t know, please leave blank.) Condition Self Family Condition Self Family Anemia Angina/Chest Pain Arthritis Bladder Infection Bleeding Problem Bone Pain Bowel Dysfunction Breathing Problem/Asthma Bronchitis /Emphysema Cancer (type): Circulation Problem/ Diabetes/Hypoglycemia Phlebitis (clotting) Difficulty Speaking Difficulty Swallowing Dizziness/Lt. Headedness Fainting Fever/Chills/Sweats Headaches Hearing Problems Heart Attack High Blood Pressure Pacemaker History of Falls Congestive Heart Disease History of Smoking History of Substance Abuse HIV Positive Nausea/Vomiting Numbness/Tingling Paralysis Seizures/Convulsions Sexually Transmitted Disease Skin Disorders Stroke Swollen Glands Urinary frequency changes Visual Disturbance Recent weight loss >10 lbs /Glaucoma Recent weight gain >10 lbs Medications with dosage: Allergies with reactions What is your normal (usual) heart rate? What is your normal (usual) blood pressure? Do you smoke (check one)? Yes No Do you use alcohol (check one)? Yes No Signature: Date:

3 Referring Physician: Primary Care Physician: (name) (address) (phone) (name) (address) (phone) Physicians you have seen for your pain problems: Date name address phone 4. Please list medical problems: 4. Please list surgical procedures you have had: 4. Pharmacy Nursing Agency Infusion Company Name address phone

4 Name Age: Ht: Wt. Handed R or L Referring physician: Primary Physician: Phone: Phone: Referred here for: Chief Complaint Pain Location #1: #2: 4. Are your disabled from working due to pain? Yes No Date last worked: 5. Lawsuit involved? Yes No Is it settled? Yes No Attorney s name: Phone: 6. Date pain began? How? (Fall?, Surgery?, etc. Please describe events below and the treatment you received for the problem: 7. Describe your pain in detail: 8. Verbal Pain Score: Algometer Score: Comfort Scale: Mild Discomforting Distressing Horrible Excruciating 9. How many hours a day is the pain at this level?: 10. What things/activities increase your pain?: 1 What things/activities decrease your pain?:

5 1 Please indicate how well you are coping with your pain by placing a mark on the line below: Well Poorly 1 Please indicate your level of functional limitation by placing a mark on the line below: Unlimited Very Limited 14. How many hours a day are you up and about?: hours 15. How many hours of sleep do you get in 24 hours?: hours 16. What medications are you taking for pain now? (name, dose, #per day, MD) 17. Pain Medications not effective for pain: 18. What pain treatments have you had in the past (check item) Acupuncture Chiropractic Surgery Physical Therapy TENS Biofeedback Pain Clinic Nerve Blocks Psychologist Infusions for pain Other 19. Present medications (OTHER than for pain): 20. List all surgeries you have had and who performed the surgery (include all nerve blocks for pain):

6 2 Please describe your mood: (frustrated, depressed, angry, happy, content, etc.) 2 History of mental health: Have you ever seen a psychiatrist/psychologist? Have you ever tried to commit suicide? Have you ever been severely depressed? Have you ever had an eating disorder? 2 How many times have you gone to the emergency room for treatment of your pain? 24. What tests have been done to diagnose your pain problem? (check the following) X-Rays CT scan MRI Bone Scan EMG/Nerve conduction tests Other Explain: 25. Allergies Reactions 26. Habits Smoking Yes No packs/years Alcohol use Occasional Social Daily Recreational Drugs Coffee/caffeine cups/day Blood thinners used? Yes No 27. Social History Education: Marital Status: Live with: Typical day: Occupation: Children: Support People: What causes you stress at this time? How do you cope?

* CC* PATIENT QUESTIONNAIRE

* CC* PATIENT QUESTIONNAIRE Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please