ACCOUNT NO. MED. REC. NO. NAME BIRTHDATE
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1 OC4501 Oregon Health & Science University *OC4501* Page 1 of 15 Thank you for completing this form prior to your appointment. Please use blue or black ink. If you have difficulty completing this questionnaire, please call us before your appointment so we can assist you. Your name: PAIN HISTORY PRESENT PAIN 1. What is the main reason for your referral to the? 2. When did your pain problems begin? / / 3. Under what circumstances did your pain begin? (select one) Accident at work At work, but not an accident Accident at home Motor vehicle collision Following surgery Following illness Pain just began with no known cause (describe) What happened? (Please describe in more detail) 4. Is your pain constant intermittent sharp dull achy stinging burning throbbing shooting 5. In general, when is your pain the worst? Morning Afternoon Evening No typical pattern 6. Where is your pain? (Shade all your painful areas on the diagram below) R L R L L R
2 Page 2 of 15
3 Page 3 of Please rank your main painful areas in order from worst to least painful. (Fill in the bubbles) The worst is: Head, face, mouth Cervical (neck) region Upper shoulder and upper limbs Thoracic (mid to upper back) region Abdominal region Lower back, lumbar spine, sacrum Lower limbs (legs, feet) Pelvic region Anal, perineal, genital Generalized pain The next worst is: Head, face, mouth Cervical (neck) region Upper shoulder and upper limbs Thoracic (mid to upper back) region Abdominal region Lower back, lumbar spine, sacrum Lower limbs (legs, feet) Pelvic region Anal, perineal, genital 8. What makes your pain worse? (Circle all that apply) bending backward bending forward climbing stairs cold cough/sneeze driving exercise heat lifting light touch sexual activity sitting standing stressful situations walking work other: (describe) 9. What relieves the pain? (Circle all that apply) bath/shower exercise heat ice lying down medications meditation physical therapy relaxation sitting standing walking other: (describe) PAST PAIN 10. Have you ever been treated at another pain management center or program? No Yes If yes, where? when? What did they do? 11. In the past 12 months (year), how many times have you been to the emergency room for your pain?
4 Page 4 of Have you been hospitalized because of pain? No Yes If yes, how many times? Have you ever had the following types of treatment for your pain problem, and what was the result? Yes Not No Indicate Pain Therapies tried tried tried Improved change Worse Comments Medications Drug Detoxification Surgery Epidural steroid injections Facet joint injections Trigger point injections Nerve (e.g., lumbar sympathetic, stellate ganglion, etc.) blocks injections (Specify: ) Spinal cord stimulation Medication pump Radiation treatment Physical therapy Exercise Manipulations/ Mobilizations Traction Exercise/ Aerobic conditioning Passive (heat, ice, gentle massage, ultrasound) Aqua/water/pool therapy Trigger point therapy/ deep tissue massage/ acupressure Occupational therapy Acupuncture Chiropractic Orthotics (corrective shoe inserts) Prosthetics (e.g. braces, supports, etc) TENS or other electric stimulation Biofeedback / relaxation Yoga Hypnosis Group therapies Psychological counseling for pain :
5 Page 5 of What medical tests have been done to evaluate your pain? (fill in bubble, date, and results) Test Date (approximate) Result (if known) X-ray CT scan Myelogram MRI Bone scan EMG EKG OTHER MEDICAL HISTORY 15. Current Medications Please list all medicatons that you are taking now or attach your own medication list. Include over the counter, herbal, vitamin, and other supplemental medications. Medication Dose Mg or # of pills How often? # times per day What is this for? Prescribing Doctor
6 Page 6 of Describe any side effects/reactions you have had to the above medications: 17. List any drug, food, or environmental allergies, and indicate what is the adverse effect/reaction: 18. List all other pain medications that you have tried in the past (check all that apply) YES OF Maximum Length of IF STOPPED, WHY? TRIED MEDICATION Dose Therapy Side Effects Not Effective Pain Medicines/Opioids Buprenorphine (Subutex, Suboxone) Codeine, Tylenol #3, #4, 222 Fentanyl lollipops (Actiq) Fentanyl patches (Duragesic) Fentanyl tablet (Fentora) Hydrocodone (Vicodin, Lortab, Norco) Hydromorphone (Dilaudid) Methadone (Dolophine) Morphine (Avinza, Kadian, MS Contin, MSIR) Meperidine (Demerol) Oxycodone (Percocet, Oxycontin) Oxymorphone (Opana) Propoxyphene (Darvon) Tapentadol (Nucynta) Tramadol (Ultram,Ultram ER, Ultracet, Ryzotl Anti-Seizure Medicines Carbamazepine (Tegretol) Gabapentin (Neurontin) Lacosamide (Vimpat) Lamotrigine (Lamictal) Oxycarbazepine(Trileptal) Tiagabine (Gabatril) Topiramate (Topamax) Zonisamide (Zonegram) Pregabalin (Lyrica) Valproic acid (Depakole) Continued on next page
7 Page 7 of 15 YES OF Maximum Length of IF STOPPED, WHY? TRIED MEDICATION Dose Therapy Side Effects Muscle Relaxants Baclofen (Lioresal) Carisoprodol (Soma) Clonazepam (Klonopin) Cyclobenzaprine (Flexeril) Diazepam (Valium) Metaxolone (Skelaxin) Methocarbamol (Robaxin) Tizanidine (Zanaflex) Not Effective Anti-Depressants Amitriptyline (Elavil) Bupropion (Wellbutrin) Citalopram (Celexa) Desipramine (Norpramin) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Hyp. perforatum (St John s Wort) Milnacipran (Savella) Mirtazepine (Remeron) Nefazodone (Serzone) Nortriptyline (Pamelor) Paroxetine (Paxil) Sertraline (Zoloft) Trazadone (Deseryl) Venlafaxine (Effexor) Anti-Anxiety/ other mood stabilizers Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Lithium (Eskalith) Olazepine (Zyprexa) Phenelzine (Nardil) Quetiapine (Seroquel) Resperidone (Risperdal) Continued on next page
8 Page 8 of 15 YES OF Maximum Length of IF STOPPED, WHY? TRIED MEDICATION Dose Therapy Side Effects Sleep Melatonin Eszopiclone (Lunesta) Ramelton (Rozerem) Temazepam (Restoril) Triazolam (Halcion) Tylenol-PM Zaleplon (Sonata) Zolpidem (Ambien) Not Effective Anti-inflammatories Celecoxib (Celebrex) Ibuprofen (Advil, Motrin) Meloxicam (Mobic) Naproxen (Aleve, Naprosyn) Nabumetone (Relafen) Rofecoxib (Vioxx) Valdecoxib (Bextra) Acetaminophen (Tylenol) Ketamine Pramipexole (Mirapex) Pyridostigmine (Mestinon) Lidocaine patch (Lidoderm)
9 Page 9 of Review of Systems: PLEASE CHECK ALL THAT APPLY Constitutional: fever chills weight loss malaise/fatigue diaphoresis weakness Eyes: blurred double vision photophobia eye pain eye discharge eye redness Gastrointestinal: heartburn nausea vomiting abdominal pain diarrhea constipation blood in stool melena Endo/Heme/Aller: easy bruise/bleed Env allergies polydipsia diabetes thyroid disorder clotting disorders Skin: rash itching nail changes skin disorders Cardiovasular: chest pain palpitations orthopnea claudication leg swelling high blood pressure PND difficulty breathing at night Genitourinary: dysuria urgency frequency hematuria flank pain urinary incontinenece Neurological: dizziness tingling tremor sensory change speech change focal weakness seizures loss of consciousness HENT: Respiratory: Musculoskeletal: Psychiatric: headaches hearing loss tinnitus ear pain ear discharge nose bleeds congestion stridor sore throat cough hemoptysis sputum production shortness of breath wheezing asthma sleep apnea myalgias neck pain back pain joint pain falls fracture herniated disc depression suicidal ideas substance abuse hallucinations nervous/anxious insomnia memory loss
10 Page 10 of How much sleep do you average each night? hours 21. Is your sleep disturbed at night? No Yes 22. Have you been told (e.g., by a bed partner) that you snore, hold your breath, or gasp for breath a lot when sleeping? No Yes 23. List all prior hospitalizations and/or surgeries Neurosurgical/Orthopedic: Craniotomy/brain surgery Cervical fusion Cervical laminectomy Lumbar fusion Lumbar laminectomy Surgical treatment of fracture Hip replacement Knee arthroscopy Knee replacement Abdominal: Hernia repair Abdominal wall defect repair Gastric bypass Colectomy Colostomy Lysis of adhesions Genitourinary: Nephrectomy Hysterectomy Cesarean section TURP/TransurethralResection Prostatectomy of Prostate Vascular/Lung: Femoral bypass Abdominal aortic aneurysm Heart valve surgery repair Coronary artery bypass graft Coronary stent placement Thoracotomy/lung surgery OTHER SURGICAL HISTORY: 24. Do you have any medical devices implanted in your body? Infusion pump No Yes Spinal cord stimulator No Yes Rods No Yes Prosthesis No Yes Pacemaker No Yes Portacath No Yes :
11 Page 11 of 15 FAMILY HISTORY 25. Have any close (biological) family members had any of the following? (If yes, fill in appropriate bubble) Mother Father Sister Brother Maternal Grand mother Maternal Grand father Paternal Grand mother Paternal Grand father Alcohol/Drug Allergies Anesthesia Arthritis Asthma Blood Disease Diabetes Genetic GI Genitourinary (GU) Headaches Heart Hypertension Lipids Psychiatry Stroke Thyroid Non-contributory Additional Family History OTHER MEDICAL HISTORY:
12 Page 12 of 15 PSYCHOLOGICAL AND SUBSTANCE USE 26. Have you ever had thoughts of: suicide or harming yourself? No Yes harming someone else? No Yes 27. Please mark the appropriate answer to the following questions. During the past month, have you been tense or anxious? During the past month, have you been depressed or discouraged? During the past month, have you been irritable and upset? When you are in pain, how often is your husband/wife/ other family supportive and encouraging? When you are in pain, how often does your husband/wife/ other family ignore you or become angry? Never Seldom Sometimes Frequently Always 28. Have you been under the care of a mental health professional? No Yes - when, how often? 29. Are you, or have you ever been, involved with any of the following? Current Use Past Use Never Used Item Cocaine Marijuana use If yes, do you have a medical marijuana Card? Methamphetamine Heroin illicit/street drug use Comments (how much and how many years? No Yes 30. Do you smoke? No Yes If yes, how many packs a day? for how long? If no, have you ever smoked? No Yes If Yes: When did you quit? How many packs per day did you smoke?
13 Page 13 of No Yes Have you felt you ought to cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you felt bad or guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a (hangover (eye-opener)? Do you drink alcohol to decrease or relieve pain? SOCIAL AND Works Cited There are no sources in the current document. 32. Marital Status Married Divorced Separated Cohabitating, not married Widowed Never married, not cohabitating 33. Partner Status Same sex partner Opposite sex partner No partner 34. Education (fill in the corresponding bubble) 8 th grade or less Some high school High school graduate or GED Some college Associate s degree Bachelor s degree Technical or trade school graduate Completed graduate or professional school degree (e.g., Master s, Ph.D., M.D., etc.) 35. How many people live in your household? (including yourself) 36. Do you have children? No Yes (list along with age and health) 37. Employment: No Yes (Select the best description for you) Homemaker Not working due to pain Not working due to other reasons On leave from work Retired due to pain Retired not due to pain Working full time Working part time 38. Describe your current (or most recent) occupation and duties When did your last work? 39. Has your job changed because of your painful condition (if working) No Yes how? 40. In the past six months, how many full days of work have you missed because of pain? < 5 days 6-14 days 3-4 weeks > 1 month
14 Page 14 of On a scale from 0 to 10, how satisfying do/did you find your current/last/most recent job? (Please circle the number) Not satisfying Very satisfying 42. On a scale from 0 to 10, how financially satisfying do/ did you find your current/last/most recent job? (Please circle the number) Not satisfying Very satisfying 43. What exercise or recreational activities do you enjoy? 44. Please mark the statements that apply to you: Disability: Not receiving or seeking disability Not receiving but seeking or planning to seek disability Receiving disability Litigation/Lawsuit(s): No (and not intending) pain-related litigation/lawsuit or legal involvements Currently in pain-related litigation/lawsuit or pain-related legal involvements Past litigation/lawsuit or legal involvements related to pain condition Motor vehicle accidents: Pain not related to motor vehicle accident Pain related to motor vehicle accident and settlement pending Pain related to motor vehicle accident but no settlement pending or necessary Do you have any other litigation or lawsuits ongoing, pending, planned, or under consideration? No Yes - explain 45. Are you under financial stress? No Yes- how? 46. Have there been any other stressful life experiences recently? No Yes- explain
15 Page 15 of 15 GOALS AND EXPECTATIONS 47. What do you expect from our pain program? (select the one best answer) A diagnosis (to help find the cause of pain) Help in coping with the pain A reduction in pain A cure No expectations Do not know what to expect 48. What types of treatment do you expect from your visits to the? (select all appropriate answers) Consultation only (advice only to you and your primary care physician) Counseling Stress Management Physical Therapy Drug treatment Acupuncture Surgery Relaxation therapy Biofeedback Injections or nerve blocks Electrical stimulation such as TENS unit Spinal cord stimulator Implanted medication pump Don t know (describe) Form completed by: Thank you for taking the time to complete this questionnaire. We will review it with you at your first visit. Provider Comments/Signature:
Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
ACCOUNT NO. MED. REC. NO. NAME BIRTHDATE
OC4501 Oregon Health & Science University *OC4501* Page 1 of 15 Thank you for completing this form prior to your appointment. Please use blue or black ink. If you have difficulty completing this questionnaire,
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE PATIENT NAME: PRIMARY DOCTOR: DATE: REFERRING DOCTOR: Please show the location of your pain by drawing on the figures below: Pain History 1. WHERE IS YOUR PAIN LOCATED? 0 Low
PAIN SOLUTIONS NEW PATIENT QUESTIONNAIRE
PAIN SOLUTIONS NEW PATIENT QUESTIONNAIRE Patient Name: DATE Primary Doctor: Referring Doctor: Please show the location of your pain by drawing on the figures below: Pain History (PLEASE FILL IN THE BUBBLES)
Legacy Pain Management Center New Patient Questionnaire
Legacy Pain Management Center New Patient Questionnaire Please complete this form prior to your visit to allow us to make the best use of our time together. Primary Care Provider: Referring Physician:
Initial Pain Questionnaire
Initial Pain Questionnaire Date: Name: Address: Last First Middle Initial Street Address City State Zip Home Phone Cell : Work: Referring Physician: Other Physicians: Age: PAIN HISTORY: What is the main
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:
NEW PATIENT INFORMATION SHEET
Akintomi A. Olugbodi M.D. 301 S. Seventh Ave. Suite 315 West Reading, PA 19611 (484) 869-2817 NEW PATIENT INFORMATION SHEET PLEASE COMPLETE THESE FORMS PRIOR TO YOUR APPOINTMENT AND BRING THEM WITH YOU
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
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 Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
NEW PATIENTS' INFORMATION SHEET
NEW PATIENTS' INFORMATION SHEET Please print clearly. Please complete all information so that your claim can be processed quickly and efficiently. Thank you! PATIENT INFORMATION (First) (MI) (Last) Name
New Patient Intake Form. Please List All Current Medications. Please shade in the areas where you have pain
New Patient Intake Form Name: Date: Referring Physician Primary Care Physician Please List All Current Medications Do you take Coumadin/Warfarin/Plavix/Lovonox or Aspirin? Yes No Last dose? Please shade
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
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
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
PATIENT DEMOGRAPHIC INFORMATION
PATIENT HISTORY FORM Date of Visit: Steven E. Levine, MD PATIENT DEMOGRAPHIC INFORMATION Name: Last First Middle Initial Home Address City / State Zip ( ) ( ) Home Phone Cell Phone Email Address Date of
PSYCHIATRY INTAKE FORM
Please complete all information on this form. PSYCHIATRY INTAKE FORM Name Date Date of Birth Primary Care Physician Current Therapist/Counselor What are the problem(s) for which you are seeking help? 1.
Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week
3 Washington Circle W, #207/208 Patient ame: Age: Chief Complaint: Please describe what you are being seen for today: What is your hand dominance (which hand do you write with)? Left Right Ambidextrous
NEW PATIENT INFORMATION FORM
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
SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD
Name: Height: Birthdate: Weight: Chief Complaint: What is the reason for your appointment? (please describe why you are here) Medications: Please list ALL medications with dosages you are currently taking,
HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions
NEW PATIENT INFORMATION FORM
1031 WEST WILLIAMS STREET, SUITE 102, APEX, NC 27502 PHONE (919) 439-7867 FAX (919) 573-9594 NEW PATIENT INFORMATION FORM All patients (new and returning) are subject to the following no-show/broken appointment
Other physician #1. #(p) List any allergies to medications. Please list below all other current medical conditions or previous surgeries
Dept. of Obstetrics and Gynecology Division of Gynecological Pain and Minimally Invasive Surgery Frank Tu, MD, MPH Sangeeta Senapati, MD, MS Howard Topel, MD Name: New Patient Intake Questionnaire Names
PAIN TREATMENT CENTER
PAIN TREATMENT CENTER Name Date Age Occupation Referring Doctor Have you ever been a patient of a Pain Clinic or Center? Yes No If yes where: When did you first notice symptoms of your pain problem? Date
* 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
SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE
Patient Name MRN DATE: SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE Date of birth Age REASON FOR VISIT Abnormal Mammogram R L please specify Lump/Thickening R L upper lower inner outer Pain R L upper
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
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
Mental Health Intake Form
Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms) ( ) ( ) Depressed mood ( ) ( ) Racing thoughts ( ) ( ) Excessive worry ( ) ( ) Unable to enjoy activities ( )
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C
Interventional Pain Medicine P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Gainesville Braselton Medical Park 1, Suite 300 Medical Plaza B, Suite 402 1315 Jesse Jewell Parkway 1404 River
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
INITIAL COMPREHENSIVE PAIN QUESTIONNAIRE
INITIAL COMPREHENSIVE PAIN QUESTIONNAIRE Name: DOB: Address: Phone number: Referring Physician name: PAIN HISTORY: Was the pain a result of a particular incident (injury, accident, illness): No Yes (please
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
PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS
PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS Advanced Spine Associates, P.A. NEW PATIENT MEDICAL HISTORY QUESTIONNAIRE Name Address City State Zip Age Date of Birth Sex M F Phone
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?
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
INITIAL PAIN EVALUTION QUESTIONNAIRE
INITIAL PAIN EVALUTION QUESTIONNAIRE We are interested in understanding more about your pain. Please help us by filling out this questionnaire. Please bring the completed questionnaire with you for your
+ Color Change - + Hearing Loss - + Apnea - + Enuresis (urine - + Tremors - + Rash -
Review of Systems: 0-1 year old Constitution neg Eyes neg GI neg Neurological neg + Activity Change - + Eye Discharge - + Reflux - + Facial Asymmetry - + Appetite Change - + Eye Redness - + Vomiting -
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
NEW PATIENT INTAKE FORM
WILLIAM S. CRAWFORD, MD NEW PATIENT INTAKE FORM Patient Name: DOB: INSTRUCTIONS: Please complete the following questionnaire before you see the doctor. Answer each question in as much detail as possible.
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Richard Heidenfelder M.D. Child, Adolescent and Adult Psychiatry 447 9th Ave San Diego, CA
*We are not accepting any New Patients who are currently taking any controlled pain medications *We are *Note: not completion accepting of the any following New Patients paperwork who and Initial are Screening
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -SPINE Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
Mental Health Intake Form
38600 Van Dyke Ave., Suite 200 Sterling Heights, MI 48313 Phone: (586) 933-5395 Fax: (586) 935-0159 Mental Health Intake Form Please complete all information on this form and bring it to the first visit.
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
New Patient Pain History Form
New Patient Pain History Form Name: Date of Birth: / / Today s Date: / / Date the Pain Began: / / Reason for visit: Describe what caused the pain (accident, injury, etc.): Pain 1. Pain/Symptom Description
Initial Pain Management Patient Questionnaire
Appt. Date: Appt. Time: Boston Out-Patient Surgical Suites North Tel Fax: 781-407-5892 Initial Pain Management Patient Questionnaire Dear New Pain Management Patient, Welcome to the New England Pain Management
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
HD CLINIC MEDICAL HISTORY FORM
HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion
Patient registration
Patient registration Name: DOB: Sex: Date: Who referred you to our office? Other Physicians you see: Occupation: Place of Employment: Marital Status (Please Circle): Single Married Separated Divorced Widowed
Happy Daisy Ltd. New Client intake Form. What are the issues for which you are seeking care?
Happy Daisy Ltd. New Client intake Form Name Date Preferred name Pronouns Referred by Date of birth Age Race What are the issues for which you are seeking care? 1. 2. 3. Please check of any of the symptoms
HEALTH HISTORY. Pharmacy: Phone# Fax# Current Medications: Dosage: Frequency:
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,
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
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
History Form for Exceptional Home-Based Care
Patient Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best care possible
The UW Pain Treatment and Research Center takes a holistic approach to your pain care.
Pain Treatment and Research Center 5249 East Terrace Drive Madison, WI 53718 Phone: (608) 263-9550 Dear Patient: The UW Pain Treatment and Research Center takes a holistic approach to your pain care. You
MCKAY UROLOGY LINCOLNTON OFFICE PATIENT HISTORY FORM
Patient name: MRN #: Current Medications (prescription and over the counter medications including vitamins, herbs, aspirin, antacids, injectables, hormones and birth control medication) If you brought
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C ADULT SPINE HISTORY For Office Use Only: HR: BP: / Name of Patient: Date: Date of Birth: Age: Height: ft in Weight: lbs Form
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
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
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
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
PAIN MANAGEMENT IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT 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 Cat scans. Patient s name:
Morris Medical Center, P.A.
Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~
Tips for Pain Management
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The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
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Pain Interventions 30 Hagen Drive, Suite Culver Rd. Suite 2 Rochester, NY Rochester, NY (Voice) (Fax)
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(Must be completed with blue ink pen) Last Name First Name Date / / Address City Zip. Home Phone Cell Phone. Social Security# Driver s License # State
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*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
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Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male
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