ACCOUNT NO. MED. REC. NO. NAME BIRTHDATE
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- Horatio Mason
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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 accident 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 5. In general, when is your pain the worst? Morning Afternoon Evening No typical pattern 6. Where is your pain? (Shade the 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? Indicate Pain Therapies tried Yes tried Not tried Improved No change Worse Comments Medications Drug Detoxification Surgery Epidural steroid injections Facet joint injections Trigger point injections Nerve (e.g., lumbar sympathetic, stellage 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 Butorphanol (Stadol) 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) Propoxyphene (Darvon) Anti-Seizure Medicines Carbamazepine (Tegretol) Gabapentin (Neurontin) 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 Not Effective Muscle Relaxants Baclofen (Lioresal) Carisoprodol (Soma) Clonazepam (Klonopin) Cyclobenzaprine (Flexeril) Diazepam (Valium) Metaxolone (Skelaxin) Methocarbamol (Robaxin) Tizanidine (Zanaflex) Anti-Depressants Bupropion (Wellbutrin) Citalopram (Celexa) Desipramine (Norpramin) Duloxetine (Cymbalta) Escitalopram (Lexapro) Fluoxetine (Prozac) Hyp. perforatum (St John s Wort) 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 Not Effective Sleep Temazepam (Restoril) Triazolam (Halcion) Tylenol-PM Zaleplon (Sonata) Zolpidem (Ambien) Anti-inflammatories Celecoxib (Celebrex) Ibuprofen (Advil, Motrin) Meloxicam (Mobic) Naproxen (Aleve, Naprosyn) Nabumetone (Relafen) Rofecoxib (Vioxx) Valdecoxib (Bextra) Acetaminophen (Tylenol) Pramipexole (Mirapex) Pyridostigmine (Mestinon) Lidocaine patch (Lidoderm)
9 Page 9 of Past Medical History and Review of Systems PLEASE CIRCLE ANY MEDICAL CONDITION OR SYMPTOMS System Comments: Cardiovascular: Respiratory: Gastrointestinal: Genitourinary: Musculoskeletal: Skin Neurological: Angina, heart disease, heart attack, irregular rhythm, high blood pressure, vascular blood flow problems, blood clots, embolism, murmurs, other Chest pain, palpitations Obstructive disease, asthma, chronic bronchitis, TB, Wheezing, shortness of breath, cough Stomach ulcers, hiatal hernia, pancreatitis, bowel problems, bleeding, gallbladder problems, hepatitis / liver disease, acid reflux/gerd, Crohn s, colitis, irritable bowel syndrome, Constipation, diarrhea, abdominal pain, heartburn Kidney, bladder, prostate, infections, bleeding, sexually transmitted disease, kidney stones, urinary continence Urinary symptoms: frequency, leaking, pain Fibromyalgia, osteoarthritis, rheumatoid arthritis, fractures Cramping, spasm, muscle pain Skin disorder, breast diseases Rash, skin growth, itching, nail changes Stroke, seizure, epilepsy, headache, neuropathy, nerve injury, memory problems, movement disorder, spinal cord injury, unconsciousness Numbness, weakness, changes in vision, coordination problems, memory loss Psychiatric: Anxiety, depression, nervous breakdown, hallucinations. Alcohol or other drug abuse. Endocrine: Allergic / Immunologic: Diabetes, obesity, thyroid abnormality, adrenal abnormality Heat or cold intolerance, change in thirst, change in appetite Auto immune disorder i.e. Lupus, Sjögren s, hay fever immune deficiency, Raynaud s syndrome HEENT Eye, ear, nose, throat diseases, conditions, or symptoms Cancer?heme Constitutional: Cancer, type?, anemia, hematologic problem Brusiing, swollen lymph nodes Recurrent fevers, weight change, heat / cold intolerance, chronic fatigue, night sweats, difficutty with sleep Pregnancy (Date of last period )
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 Date Reason/ Procedure or Surgery (in detail) 24. Do you have any medical devices implanted in your body? (Pacemaker, portacath, pump, rods, prosthesis, etc. ) 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) Heart Hypertentsion Lipids Psychiatry Stroke Thyroid Non-contributory Additional Family 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 Item Comments (how much and how many years?) Marijuana use If yes, do you have a medical marijuana No Yes card? Cocaine Methamphetamine Heroin illicit/street drug use
13 Page 13 of No Yes Have you ever felt the need to cut down on your drinking? Have you ever felt annoyed by people complaining about your drinking? Have you ever felt guilty about your drinking? Do you ever drink an eye-opener in the morning to relieve the shakes? Do you drink alcohol to decrease or relieve pain? SOCIAL AND WORK 31. Marital Status Married Divorced Separated Cohabitating, not married Widowed Never married, not cohabitating 32. Partner Status Same sex partner Opposite sex partner No partner 33. 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.) 34. Employment: (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 35. How many people live in your household? (including yourself) 36. Do you have children? No Yes (list along with age and health) 37. Describe your current occupation and duties (if working) 38. Has your job changed because of your painful condition (if working) No Yes how? 39. 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 41. 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 42. What exercise or recreational activities do you enjoy? 43. Are you, or have you ever been, involved with any of the following? 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 44. Are you under financial stress? No Yes- how? 45. Have there been any other stressful life experiences recently? No Yes- explain
15 Page 15 of 15 GOALS AND EXPECTATIONS 46. 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 47. 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:
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 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,
PAIN SOLUTIONS NEW PATIENT QUESTIONNAIRE
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NEW PATIENT INFORMATION SHEET
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Initial Pain Questionnaire
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Legacy Pain Management Center New Patient Questionnaire
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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
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* CC* PATIENT QUESTIONNAIRE
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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:
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 PATIENTS' INFORMATION SHEET
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COMPREHENSIVE REHABILITATION PAIN QUESTIONNAIRE. Date of Visit. Statement of Problem: Date of Injury/onset of condition: Date of birth: Age
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PAIN INFORMATION SHEET
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PSYCHIATRY INTAKE FORM
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SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD
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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
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
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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
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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
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
NEW PATIENT INFORMATION FORM
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Amarillo Surgical Group Doctor: Date:
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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
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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
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Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
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The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
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PATIENT DEMOGRAPHIC INFORMATION
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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 ~
PAIN TREATMENT CENTER
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Medical History Questionnaire
Date Medical History Questionnaire Name DOB Reason for visit When did symptoms first appear Is the condition getting worse? Please rate your pain 0 1 2 3 4 5 6 7 8 9 10 No Pain Extreme Pain Please circle
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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
Please fill out this form as completely as possible. This information will determine how we treat your pain problem.
Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your
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?
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Patient History Form
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JOSE G. VELIZ MD, INC. Diplomate of the American Board of Interventional Pain Management Diplomate of the American Board of Anesthesiology Diplomate of the American Board of Pain Medicine Fellow of Interventional
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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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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form
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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?
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 ( )
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
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Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week
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Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire
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Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
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NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
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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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Trinity Pain Center New Patient History Form
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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
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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.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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Florida Hospital Spine Center Patient Intake Form
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NEW SPINE PATIENT QUESTIONNAIRE
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INITIAL COMPREHENSIVE PAIN QUESTIONNAIRE
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GIDEON G. LEWIS, M.D.
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