HEALTH HISTORY. Pharmacy: Phone# Fax# Current Medications: Dosage: Frequency:
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1 HEALTH HISTORY Patient Name: Birth Date: Visit Date: Referring Physician: Reason for visit: Pharmacy: Phone# Fax# Current Medications: Dosage: Frequency: S. Blake Kelly, MD James Lynch, MD Jack Marshall, MD Brandon Funk, PA-C
2 List all pain medication taken in the last 2 weeks: If you have Depression or anxiety, how well has it been controlled in the past 3 months? Excellently Well Could be better Poorly History of allergy or adverse reactions: (circle all that apply) Antibiotic Allergy: Pain Medication: Penicillin Morphine (Kadian, Embeda, Avinza) Demerol Sulfa Codeine (Tylenol #3) Tramadol Mycins Hydrocodone (Norco, Lortab) Toradol Tetracycline/Doxycycline Oxycodone (Percocet, Oxycotin) Talwin Cephalosporins Fentanyl (Duragesic) NSAIDs Tape/Iodine Dilaudid (Hydromorphone) Tylenol Other: Other: Other: Social History: (Circle all that apply) Drink Alcohol: Occasionally Frequently Daily Use Tobacco packs per day, how long? Use street drugs or have a history of substance abuse/addiction Admitted to the hospital for psychiatric treatment, date: Admitted to the hospital for drug or alcohol treatment, date: Are you pregnant or trying to become pregnant? Yes No Marital Status: Married Single Widowed Number of children: Level of Education: Occupation: Employer: Currently Working? Yes No Disabled? Yes No Permanent/temp? Date: Are you or have you even been a victim of domestic violence or sexual abuse? Yes No
3 Please list all current doctors involved in your care at this time: Physician Specialty Date of last appointment Previous Treatments: If yes, date of last treatment Physical/Occupational Therapy Y N Chiropractor/Manipulation Y N Acupuncture Y N Hypnosis Y N TENS unit Y N Psycho/Psychiatric Therapy Y N Tests: Lumbar MRI Y N Thoracic MRI Y N Cervical MRI Y N CT Scan Y N Myelogram Y N Nerve Conduction Y N Bone Scan Y N Discogram Y N Describe below any further pertinent health history.
4 Medical History: (Please mark appropriate response) Anemia, currently Gastrointest. Disease Neck pain Arthritis (osteo or rheum) Gout Low back pain Auto-immune disorder Headaches (daily, migraine, tension) Chronic pain, Area Anxiety Heart disease Knee pain, right left Blood disease/anemia Hepatitis A _ B C Hip pain, right left Bipolar disorder High blood pressure Foot/ankle, right left Bone disease/osteoporosis High Cholesterol Shoulder, right left Wrist/hand, right Blood Transfusion HIV/AIDS left Cancer - Type Irritable bowel Pelvic pain Coronary Artery Disease Kidney disease Spinal Stimulator Congestive Heart Failure Kidney stone, number Neck, lumbar COPD/Emphysema Liver disease Crohn's disease Loss of consciousness Dementia Pacemaker Diabetes Psoriasis DVT/Blood clot Schizophrenia Dysrhythmia Seizure disorder Depression Stroke/mini-stroke Frequent falls Thyroid disease Vascular disease
5 Surgical History: (Please mark the appropriate response) No previous Surgery Other surgical history: Spinal Fusion, Date Appendectomy Neck Thoracic Lumbar Coronary Artery Bypass Spinal Laminectomy, Date Cardiac Procedure Neck Thoracic Lumbar Gall bladder removal Epidural Steroid Injection Hernia Neck, date Lumbar, date Hysterectomy Thoracic, date Joint replacement, Area Rhizotomy (nerve ablation) Neck/Lumbar Neck Thoracic Lumbar Neck/Lumbar Tonsillectomy Vertebral Disc replacement Vascular procedure Date: Neck Lumbar
6 On the diagram, shade in the areas where your pain is located. R L L R R L Mark your level of pain on this scale None Severe 0 10 Circle a FEW words that best describe your pain Flickering Pricking Pinching Tugging Hot Tingling Quivering Boring Pressing Pulling Burning Itchy Pulsing Drilling Gnawing Wrenching Scalding Smarting Pounding Stabbing Cramping Crushing Searing Stinging Dull Tender Cool Annoying Spreading Tight Sore Tiring Cold Troublesome Radiating Numb Hurting Exhausting Freezing Miserable Penetrating Drawing Aching Nagging Unbearable Intense Piercing Squeezing
NECK PAIN QUESTIONNAIRE
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PAIN HISTORY. Please describe your pain:
Name: Date: PAIN HISTORY Please describe your pain: List surgeries/hospital admissions and dates (Skip if you have already provided this information on Medical History Questionnaire): Please list current
Please do not write in this space.
Facial Problem Questionnaire I. Name Age Date Referred by II. Which of the following do you have (circle all that apply) Headaches Neck Pain Jaw pain Ear Pain Facial Pain Bite Problems Damaged teeth Other
New Patient Intake Form
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PAIN SERVICE REFFERAL QUESTIONNAIRE
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Patient Name: Date of Birth:
Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?
Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C
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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:
Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT
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Patient Name Date MR#: FLORIDA ORTHOPAEDIC INSTITUTE. Race: Ethnicity: (Circle one) Hispanic / Not Hispanic
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New Patient Intake Form. Please List All Current Medications. Please shade in the areas where you have pain
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PAIN INFORMATION SHEET
PAIN INFORMATION SHEET PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE SENSATIONS DESCRIBED BELOW. PLEASE USE THE APPROPRIATE SYMBOL & INCLUDE ALL AREAS. **** ==== OOOO XXXX //// ACHE **** NUMBNESS
Facial Problem Questionnaire
Facial Problem Questionnaire Name Age Date Referred by _ Referring Dr. s Phone # and Email: 1. Which of the following do you have (circle all that apply) Headaches Neck Pain Jaw pain Ear Pain Facial Pain
Numbness: o o o o o. Grade your overall pain. Pain Rating Scale Mosby. Worst Possible Pain. No Pain HURTS LITTLE MORE HURTS EVEN MORE
Patient Name: Original Referring Physician: Current PCP: PAIN DIAGRAM Is your condition the result of a: Work injury? YES NO Auto accident? YES NO Date of Injury: / / Please mark the areas of discomfort
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New Patient Pain History Form
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SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell
Employed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe
PLEASE NOTE: This file must be saved to your desktop before and after completing! PATIENT INFORMATION Date First Name SSN Sex Marital Status Middle Name Birth Date Last Name Height Spouse Name Address
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Initial Pain Management Patient Questionnaire
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* 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
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
New Patient Intake Form
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COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name
FACIAL PAIN DYSFUNCTION EVALUATION. Name Birthdate / / Age. Home # ( ) Cell # ( ) Work # ( ) Address Apt. # City State Zip.
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Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:
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Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History
MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information
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PLEASE NOTE: This file must be saved to your desktop before and after completing!
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Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
Primary (First) Complaint and Location
Name: : File #: Case Type: Sex: Birth : Age: Social Security #: Address: Residence and Mailing City State Zip Code Home Phone: Mobile Phone: Email: Occupation: Employer: Work Phone: Marital Status: S M
Family First Chiropractic
Family First Chiropractic Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of