New Patient Pain History Form
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- Eleanore Waters
- 5 years ago
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1 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 Mark the affected areas on your body where you feel your typical pain and/or symptom and place a star by where you are most affected. Page 1 of 5
2 2. How would you describe the kind of pain/associated symptoms that you have: Sharp Stabbing Aching Dull Burning Cramping Pins and needles Throbbing Numbness If so, where? Weakness If so, where? 3. Pain compared to when it first started: Improved by % Worsened by % No Change 4. Pain Severity: If 0 is no pain and 10 is the worst pain imaginable, please note your pain over the past two weeks by circling the appropriate number: Pain at its worst: [0 1 2] [ ] [8 9 10] Pain at its least: [0 1 2] [ ] [8 9 10] Pain on average: [0 1 2] [ ] [8 9 10] Pain Frequency: Constant Intermittent, # of hours in pain per day Time of Day Pain is at its Worst: Morning Afternoon Evening Nighttime How Often You Stop Activity Due to Pain: Never Rarely Occasionally Several Times a Day Spend Most of the Day Lying/Sitting 5. Activities which relieve pain: 6. Activities which increase pain: 7. Medications you take to relieve pain (please list all): 8. Current exercise activities: Diagnostic tests performed for this condition: Test Date Location X-Rays CT Scan MRI Bone Scan EMG (nerve test) Other List the doctors (Primary Care, MD Specialist, Osteopathic Specialist, Chiropractor, or Therapist) you have seen in the last year for your condition: Doctor s Name Type of Doctor Location Approximate Date Effect of treatment(s) you have had, or are currently receiving, for your pain: Treatment Helped Made Things Worse No Difference Currently Receiving Heat/Ice/Ultrasound Massage TENS Unit Physical Therapy Epidural Injections Back Brace Acupuncture Mental Healthcare Chiropractic Care Page 2 of 5
3 New Patient Health History Form Name: Today s Date: / / Date of Birth: / / PCP: Allergies and Medications: Medication allergies: List any other allergies: Current Medications: Medication Dose/Frequency Used to Treat For How Long? Past Medical History (please check those which apply): Hypertension Heart Disease Hyperlipidemia Nerve/Muscle disease Stroke Seizures Migraine Fibromyalgia Chronic Pain (>3 months) Diabetes Mellitus GERD/Ulcers/Gastritis Depression Motor Vehicle Accident Thyroid Disease Pulmonary Kidney Disease Anxiety Substance Abuse Cancer Work Related Injury Fractures DVT Prostate Problems Nerve/Muscle Disease (please specify): Any other relevant medical history: Family History (please place a check mark indicating relation of relative) Page 3 of 5
4 Other relevant family history: Surgical History (please check those which apply and provide approximate year performed): Appendectomy Back Surgery Breast Surgery C-Section Gall Bladder Heart Surgery Hernia Repair Hysterectomy Neck Surgery Orthopedic and/or Joint Surgery Tonsillectomy Any other relevant surgical history: Social History 1. Marital status: Married Domestic Partner Widowed Never Married Divorced/Separated 2. Whom do you live with: Spouse Children Parents Roommate(s) Partner Alone Other 3. Highest grade or level of education completed: 4. Tobacco Use: Never Current Former (Quit Date: ) a. Type(s) of tobacco used: Cigarettes Cigars Pipe Chewing Tobacco b. Average number of packs per day: Age when started using tobacco: 5. Cups of coffee per day? Cups of other caffeinated beverages per day? 6. Do you use alcohol? Yes No If so, average number of alcoholic beverages per week: a. Times in the past year you consumed 4+ drinks in one day: b. Do you use alcohol to control your pain? Yes No 7. Drugs you have used: a. at any time: Stimulants Hallucinogens Marijuana Cocaine Meth None of these b. in the past 12 months: Stimulants Hallucinogens Marijuana Cocaine Meth None of these 8. Are you currently employed? Yes No a. If so, how many hours per week do you work? b. Where do you work? c. What type of work do you do? 9. Are you currently on disability or involved in a disability claim? Yes No 10. Are you currently involved in a legal claim? Yes No a. If so, are you represented by an attorney? Yes No If yes, please provide name: Review of Symptoms (Check all those which apply): Low Back Pain Dizziness Fever Wheezing Joint Pain Headaches Weight Loss Coughing Joint Swelling Urinary Frequency Night Sweats New Rash Muscle Pain Loss of Control of Urine Vision Change Psoriasis Night Pain Loss of Control of Bowels Double Vision Skin Breakdown Numbness Constipation Difficulty Swallowing Depressed Mood Tingling Nausea Chest Pain Sleep Problems Weakness Vomiting Palpitations Anxiety Black Stools Shortness of Breath 2 or More Falls in the Last Year OR 1 With Injuries Page 4 of 5
5 Tualatin Map and Directions From the South Travel North on I-5 Take exit 289, turn right at the light Follow the curve to the right, proceed on SW 65 th Ave Turn left into the entrance to Legacy Meridian Park Medical Center Make the second left and park in any designated patient space From the West Travel to I-5 Follow remaining directions from the South or North (according to your proximity to the Nyberg St exit) From the East Travel West on I-205 Take exit 3, turn right onto Stafford Road Turn left onto Borland Road and proceed to SW 65 th Avenue (approximately 4 miles) Turn right onto SW 65 th Ave Make the first right into Legacy Meridian Park Medical Center Make the second right and park in any designated patient space From the North Travel South on I-5 Take exit 289, turn left at the light Cross the overpass and proceed on Nyberg Road Follow the curve to the right, proceed on SW 65 th Ave Turn left into the entrance to Legacy Meridian Park Medical Center Make the second left and park in any designated patient space Page 5 of 5
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
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
New Patient Pain Evaluation
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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
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
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:
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Pain Drawing. Name: Today s Date: How were you referred to the office: Visual Analog Scale
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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
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
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