Comprehensive History, Consult, and Evaluation Form
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1 1 Comprehensive History, Consult, and Evaluation Form 1.Patient Information: Today s Date: Mr. Ms. Miss Mrs. Dr. Name Age: Date of Birth: Male Female Address: City/State/Zip: Home Phone: Work Phone: Cell Phone: Employed By: Physician Name & Address: Referred By: What are the reasons for your visit today? When did your symptoms start? What do you believe is the cause of your pain or present condition?
2 2 How does your present condition affect your quality of Life? Have you had to change the way you do things or eliminate certain activities from your life? Has anyone in your family had a similar condition to what you are experiencing now? If so, who? 1. Please rank your complaints in order of severity with #1 being the most severe complaint, #2 the next, etc. 2. Then rate your complaints for frequency, intensity, and duration. RANK OF COMPLAINT COMPLAINT Back Pain Dizziness Ear Congestion Ear Pain Eye Pain Facial Pain Fatigue Grind Teeth Headaches Jaw Clicking Jaw Joint Noises Jaw Locking Jaw Pain Limited Mouth Opening Migraines Muscle Soreness Muscle Twitching Neck Pain Pain when Chewing Ringing in the Ears Shoulder Pain Sinus Congestion Throat Pain Visual Disturbances Other (write in) FREQUENCY (1-4) 1)seldom, 2)occasional 3)frequent, 4)every day INTENSITY (0-10) 0=no pain 10=severe pain DURATION 1)Min., 2)Hrs, 3)Days, 4)Constant
3 3 Place an X anywhere on the diagram where you experience pain. List of Health Care Providers: List the name, area of specialty, and address of all healthcare providers that are currently taking care of you. This should include, but is not limited to, primary care Physician, ENT, Neurologist, Rheumatologist, Dentist, Chiropractor, Physical Therapist, Acupuncturist, Nutritionist, Psychiatrist, Psychologist, Massage Therapist, etc. :(attach an additional sheet if necessary) List all previously diagnosed medical conditions: (attach additional sheet if more space is needed) List all traumatic injuries or accidents, and when they occurred from childhood until the present: (examples: car accident, work related accident, fall, fight, athletic endeavor): (attach additional sheet if more space is needed)
4 4 List all surgeries, when they occurred, and who performed them: (attach additional sheet if more space is needed) Do you, or have you ever used tobacco products? no, yes. If yes, explain: (type, years of use, use per day) Do you exercise regularly? Explain: What is your daily caffeine exposure? (coffee, tea, soda, energy drinks, etc.- cups, cans, bottles, etc./day) On average, how many hours of sleep do you get per night? Do you wake up in the middle of the night? no, yes. If yes, how often, and for what reason? Do you use sleeping aids in order to get a sound sleep? no, yes. If yes, please explain: (medications, CPAP, mouth appliances, nasal strips, sound therapy, light therapy, other): Do you snore? no, yes Have you been diagnosed with sleep apnea or have you ever been told that you stop breathing for periods of time while you are sleeping? no, yes. If yes, please explain: Do you wake up feeling refreshed? no, yes. If no, please explain: Emotional Factors: (circle all that apply and explain below) a. Negative attitude b. Anxious c. Depressed d. Frustrated e. Nervous f. Fatigue g. Job Stress h. Personal problems
5 5 List all allergies: List of medication: Prescription medications: List all prescription medications, dosage, when in the day you take it, and who prescribed it: (attach additional sheet if more space is needed) Non-prescription medications, vitamins, supplements, etc.: (attach additional sheet if more space is needed) List all health care providers that you have seen for your present condition. Include their area of specialty, treatment provided, effectiveness of treatment, and date of treatment: (effectiveness scale 0-3 where 0=not effective and 3=very effective) Provider Name Specialty Treatment Rendered Effectiveness Date A B C D E
6 6 F G H Describe duties at your place of employment. Do your work responsibilities include any of the following (check all that apply): prolonged computer use heavy lifting prolonged standing extended driving awkward body positioning prolonged phone use Please list your leisure time activities, hobbies, and physical activities: Musculoskeletal: Osteoarthritis: yes no Rheumatoid Arthritis: yes no Fibromyalgia: yes no Other: Circulatory: Vascular disease: Ear-Nose-Throat: Heart disease Blood Disorders: Hearing Loss: right left Surgical History:
7 7 Sinusitis: yes no Other: Headache: yes no Have your headaches ever been diagnosed as: Migraine Cluster Tension Other: How often: Times/week Daily Other: Duration of episodes: Location: _ Is there a pattern to onset: on rising late afternoon waken in night menses weather related Response to medications: In recent months have the headaches: Frequency: increased decreased unchanged Duration: increased decreased unchanged Intensity: increased decreased unchanged Headaches associated with: Nausea: yes no Blurred vision: yes no Excessive tearing: yes no Toothache: yes no which teeth: Other associated symptoms:
8 8 Muscle Aches: Place in appropriate box. Neck Pain: none mild moderate severe intermittent constant Left Right INTMT. CNST. MILD MOD. SEV. NONE NONE SEV. MOD. MILD CNST. INTMT. SHOULDER UPPER BACK LOWER BACK HIP THIGH CALF Numbness or diminished sensation in: Fingers: yes no Describe: Hands: yes no left right Describe: Arms: yes no Describe: Elsewhere: yes no Describe: Oral/Facial: Jaws clenched upon awakening: yes no Clenching & grinding during sleep: yes no Clenching & grinding during waking hours: yes no Facial muscle fatigue: yes no Describe: Facial muscle pain: yes no Describe: Nasopharyngeal (nose/throat): Chronic Sinusitis: yes no Chronic stuffy nose: yes no Chronic nasal discharge: yes no Post nasal drip: yes no
9 9 Do you suffer from allergies: yes no which ones: Do you receive allergy shots or medications: yes no Describe: Are your nasopharyngeal allergy symptoms: constant intermittent seasonal EAR: Tinnitus (ringing in ears): Right: yes no constant intermittent Left: yes no constant intermittent Ear Pain: Right: yes no constant intermittent Left: yes no constant intermittent Stuffiness Sensation: Right: yes no constant intermittent Left: yes no constant intermittent Loss in hearing acuity: yes no severe mild gradual sudden First noticed change: worsening same Vertigo (feeling of moving around in space or objects spinning around you): yes no when:
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The UW Pain Treatment and Research Center takes a holistic approach to your pain care.
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Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
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