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1 SWEDISH PAIN SERVICES: Initial Visit Questionnaire Name Date of Birth Today s Date We realize that some of the questions might not address your exact situation but please answer them to your best ability. Approximately how many years have you had your pain? Years How many areas of your body are now affected by chronic pain? or more Please indicate where your present pain is: What number best describes your pain on average in the last week: Pain as bad as you pain can imagine Please check the box of the number that best describes how, during the last week, pain has interfered with your: Enjoyment of life General Activity interference Completely interferes Activity difficulty: In order to monitor it during the course of your treatment, please list one important activity that is currently difficult for you to perform: How would you rate the difficulty you have performing this activity over past week? Extreme difficulty difficulty CC641 Rev. 11/17
2 Pain and everyday activities: Please answer every section, and mark in each section the one box that applies to you. We realize you may consider that two of the statements in any one section relate to you, but please mark the box that most clearly describes your problem. Section 1- Pain intensity: I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment Section 2 - Personal care (washing, dressing, etc. ) I can look after myself normally without causing extra pain. I can look after myself normally, but it causes extra pain. It is painful to look after myself, and I am slow and careful. I need some help but I manage most of my personal care. I need help every day in most aspects of self-care. I do not get dressed. I wash with difficulty and stay in bed. Section 3 - Lifting: I can lift heavy weights without causing extra pain I can lift heavy weights, but it causes me extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if items are conveniently positioned (eg. on a table). Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can lift only very light weights. I cannot lift or carry anything at all. Section 4 - Walking: Pain does not prevent me walking any distance Pain prevents me from walking more than 1 mile. Pain prevents me from walking more than 1/2 mile. Pain prevents me from walking more than 100 yards I can walk using a stick or crutches. I am in bed most of the time Section 5 - Sitting: I can sit in any chair for as long as I like. I can only sit in my favorite chair as long as I like. Pain prevents me from sitting more than one hour. Pain prevents me from sitting more than 30 minutes. Pain prevents me from sitting more than 10 minutes. Pain prevents me from sitting at all. Section 6 - Standing: I can stand as long as I want without extra pain. I can stand as long as I want but it gives me extra pain. Pain prevents me from standing for more than 1 hour. Pain prevents me from standing for more than 30 minutes. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing at all. Section 7 - Sleeping: My sleep is never disturbed by pain. My sleep is occasionally disturbed by pain Because of my pain I have less than 6 hours sleep. Because of my pain I have less than 4 hours sleep. Because of my pain I have less than 2 hours sleep.. Pain prevents me from sleeping at all. Section 8 - Sex life (if applicable): My sex life is normal and causes no extra pain My sex life is normal but causes some extra pain My sex life is nearly normal but is very painful My sex life is severely restricted by pain My sex life is nearly absent because of pain Pain prevent any sex life at all Section 9- Social life: My social life is normal and gives me no extra pain. My social life is normal, but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, eg, sport Pain has restricted my social life, and I do not go out as often. Pain has restricted my social life to my home. I have no social life because of pain. Section 10 - Traveling: I can travel anywhere without extra pain. I can travel anywhere, but it gives me extra pain. Pain is bad, but I manage journeys over two hours. Pain restricts me to journeys of less than one hour. Pain restricts me to necessary journeys under 30 minutes Pain prevents traveling except to receive treatment.
3 Over the last two weeks, how often have you been bothered by the following problems? t at all Several days Over half the days Nearly every day Feeling nervous, anxious on edge t being able to control or stop worrying Worrying too much about different things Trouble relaxing Being so restless that it s hard to sit still Becoming easily annoyed or irritable Feeling afraid as if something awful might happen t at all Several days Over half the days Nearly every day Little interest or no pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or you have let yourself or family down Trouble concentrating on things, such as the newspaper or watching television Moving or speaking so slowly that other people have noticed. Or the opposite being so fidgety or restless that you have been moving around more than usual Thoughts that you would be better off dead or hurting yourself In your life have you ever had any experience that was so frightening, horrible, or upsetting that in the past month you: Yes Have had nightmares about it or thought about it when you did not want to? Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? Were constantly on guard, watchful, or easily startled? Felt numb or detached from others, activities, or your surroundings? With the last two weeks in mind, if you have had back pain, please answer the following questions: Disagree Agree My back pain has spread down my leg(s) at some time in the past 2 weeks I have had pain in the shoulder or neck at some time in the past 2 weeks I have only walked short distances because of my back pain In the past 2 weeks I have dressed more slowly than usual because of back pain It s really not safe for a person with a condition like mine to be physically active Worrying thoughts have been going through my mind a lot of the time I feel that my back pain is terrible and it s never going to get any better In general I have not enjoyed all the things I used to
4 Overall how bothersome has your back pain been over the last 2 weeks t at all Slightly Moderately Very much Extremely Sleep Has anyone observed you stop breathing during your sleep? Have you ever had sleep study? If yes, were you told you had sleep apnea? If yes, do you use a CPAP or other sleep device to help you sleep? Do you often have problems with restless legs (urge to move the legs, worse at rest, better with activity, worse at evening and night)? Do your legs frequently jerk during sleep? Yes Fatigue/tiredness ne Mild Severe Very Severe How would you rate your fatigue on average? Sleep Disturbance in the past seven days My sleep quality was Very poor Poor Fair Good Very Good In the past 7 days t at all A little bit Somewhat Quite a bit Very much My sleep was refreshing I had a problem with my sleep I had difficulty falling asleep My sleep was restless I tried hard to get to sleep I worried about not being able to sleep I was satisfied with my sleep
5 Yes of substance abuse Alcohol Illegal Drugs Prescription drugs Personal history of substance abuse Alcohol Illegal Drugs Prescription drugs Age between years History of preadolescence sexual abuse Psychological disease ADD Attention Deficit Disorder Obsessive compulsive disorder Bipolar disorder Schizophrenia Depression Family History Yes Mother Father Fathers mother Fathers father Mothers mother Mothers father Other family member of arthritis of fibromyalgia of migraines of heart disease of diabetes
6 Work History: What is your occupation? Are you: Employed full time Unemployed because of pain Retired because of pain In school or retraining Employed part time Unemployed because of other reasons Retired but not because of pain Homemaker Overall, on a scale of 0-10, how close are you to returning to work? (10 meaning ready to work full time, 0 meaning you are not even close to work at any job.) Do you have an attorney working on your injury claim?... Yes Please identify 2-3 goals that you would like to achieve. A goal is something you would like to achieve and you feel is possible over the next 2 weeks To the best of your recollection, how many different healthcare providers have you seen in the LAST 6 MONTHS for your pain? Number of times you have seen them (approximately) General practice (i.e. family medicine, internal medicine): Medical specialists: Pain specialists: Surgical specialists: Psychologists, psychiatrists, or other mental health professionals: Physical therapists: Chiropractors Complimentary and alternative healthcare professionals (i.e naturopath, massage, accupuncture):
7 Allergies: Are you allergic to any medication?... Yes If YES, please list them Medication Reaction Past medications tried for pain: (medications you are no longer taking) Name of drug Strength Number per day Reason for stopping? ( side effects, ineffective, other) What over the counter (non prescription) medications or herbal preparations are you taking? (Eg Advil, Aleve, Tylenol, Benadryl) Name of drug Strength Number per day What pain medications are you taking eg Percocet, oxycodone, hydrocodone, gabapentin? Name of drug Strength Number per day What non-pain medications are you taking eg for high blood pressure, cholesterol, diabetes? Name of drug Strength Number per day
8 Past Medical History: Have you had any of these conditions either now or in the past? known Problems Alcohol Addiction Anesthesia Reaction Arthritis Asthma Cancer COPD Diabetes Drug Addiction Acid reflux Stomach ulcer Depression Panic disorder Bipolar disorder Obsessive-compulsive disorder Yes Yes Heart Disease Heart Failure High Blood Pressure Kidney disease Mental Health Disease Liver problems Stroke Thyroid Disease Schizophrenia Post Traumatic stress disorder Gout HIV positive disease Any unexplained weight loss of more than 10 pounds in the last 6 months Review of systems: Do you suffer from Night sweats, unexplained falls Eye pain Sinus pain, ear pain, throat pain, pain on swallowing Chest pain, unable to lie flat at night because of shortness of breath Abdominal pain, nausea vomiting, diarrhea, constipation, bloating, black stools, an eating disorder Incontinence, burning urine, frequent urination Joint swelling, Breast pain, breast lumps, breast discharge Seizures, burning discomfort, numbness, poor balance, speech problems, headaches Tremor, palpitations, needing to drink a lot of water, chronic low blood pressure Prolonged bleeding after dental extraction, refused for blood donation Social History What is your marital status? Married Divorced/Separated Single Single but living with someone Do you have any children?... Yes If yes, what are their ages? Have you had a stress or change in a significant relationship within the past 12 months? Yes If yes, please explain: Living Situation Live Alone With Family With Friends Homeless Other
9 Surgical History Have you had surgeries?... Yes IF YES, please list them with year of surgery Name of surgery, example: spine fusion L5-S1 Year 2012 Tobacco Use - Never - Former Smoker Yes - Occasional smoker Yes - Smoke every day If yes, Ready to quit?... Yes Packs/Day Alcohol Use Do you drink alcohol?... Yes If yes, Drinks per week: Glasses of wine Cans or bottles of beers Shots of liquor Recreational Drug Use (not prescribed to you) Do you use recreational drugs? Yes If yes, Drug Type? Benzodiazepines (Xanax, Ativan, Valium) Cannabis Cocaine Methamphetamine Opiates Use per week Other
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Address Street Address City State Zip Code. Address Street Address City State Zip Code
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Richard Senysyzn, MD Psychiatry for Adults 1260 River Acres Drive New Braunfels, TX , Fax. (888)
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