PATIENT INTAKE FORM. Name Date of Birth Age. Address Sex. Home Phone Primary Care Physician. Address Phone # Referring Physician.

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PATIENT INTAKE FORM Date Name Date of Birth Age Address Sex Home Phone Primary Care Physician Address Phone # Referring Physician Address Phone # CHIEF COMPLAINT: Describe in your own words why you came to the Pain Clinic today: What are your expectations from your visit to the Pain Clinic today? HISTORY OF PRESENT ILLNESS: When did you first notice your pain/problem? What do you think caused your pain/problem? Where is your pain: (Please draw on figure on the last page) Is your pain worse on one side than the other, if so, which side? Describe your pain) for example, dull, sharp, burning, achy, etc.) Does your pain migrate or radiate to other parts of your body, if so, where?

Please use the following scale to rate your pain below: 0-10 0 meaning no pain and 10 meaning severely painful.. My pain at BEST is My pain NOW is My pain at its WORST is List the things that make your pain better List the things that make your pain worse How is your sleeping? Have there been any changes in your mood? (for example, irritable, sad, not eating, etc.) If so please explain What have other physicians told you is causing your pain? Has your physician prescribed or have your tried any of the following forms of treatments for pain relief? If so, please note the date/s you tried or began treatment, the effectiveness (for example, good, bad, very, etc.) and the percentage of pain relief, if any. DATES EFFECTIVENESS %PAIN DECREASED Restricting activity Medication/s Ice/Heat Physical/occupational therapy Tens unit Chiropractic Biofeedback/counseling Nerve Blocks/Injections Surgery Is this pain the result of a work related accident: If yes, is legal action or an insurance settlement pending? If yes, describe the current status of such action

If no, do you plan to pursue legal action or insurance settlement in the future? Have you had any of the following pain related evaluations and if so please give the date/s and the facility in which you had the evaluations. DATES FACILITY(S) X-rays Cat scans MRI Myelogram Bone Scan Nerve and Muscle tests) EMG s Previous Medical History: Have you ever been diagnosed with any of the following medical conditions, and if so, when? DATE DIAGNOSED DATE DIAGNOSED Asthma/COPD High Blood Pressure Heart Disease Ulcers/GERD Kidney problems Hepatitis Bleeding tendencies Cancer Diabetes Other Previous Surgical History: Please list any surgeries, that you have had and the dates of those surgeries below: Surgery Date of Surgery Your Height Your Weight Drug Allergies Reaction Medications Dose

If you are currently taking a blood thinner please CIRCLE which one you are taking: LOVENOX PLAVIX COUMADIN REFLUDAN HEPARIN TICLID Social History: I work at I am retired from I have missed work in the month (Y/N) If yes, how many days? Tobacco use Y/N packs per day # years Quit Date Alcohol use Y/N amount/day History of abuse? Y/N Single Married Divorced Widowed I am: Pregnant Planning to become pregnant Y/N Does anyone live with you? If so, who? Education background: (circle all that applies) GED High School College Technical School Other Family History: Does any of your immediate family members have a history of a major disease: (For example: heart disease, lung disease, bone disease) if so, please list here: Mother Father Sister Brother Review of Systems: Do you have any of the following symptoms: Please list all symptoms that apply. CONSTITUTIONAL Fever/chills/sweats/weight change EYES,EARS, NOSE Headaches/eye, ear or nose problems CARDIOVASCULAR Chest pains/murmur/fluttering in chest RESPIRATORY

Short of breath/productive cough GASTROINTESTIONAL Diarrhea/constipation/incontinence NEUROLOGIC Weakness/loss of balance/falls SKIN Skin rash/hives/ulcers PSYCHIATRIC Depression/anxiety ENDOCRINE Diabetes/thyroid HEMATALOGIC Bleeding problems/anemia/swollen nodes ALLERGY/IMMUNOLOGIC Seasonal allergies/asthma/hay fever LATEX ALLERGY Have you ever been tested for a Latex Allergy? Y/N If so, what were the results? (Negative/Positive) Do you have eczema or problems with rashes: (Y/N) Do you have swelling, itching, hives or other symptoms after contact with: Balloons (Y/N) Dental Examinations or Procedure (Y/N) Vaginal or Rectal Exam (Y/N) Using a Diaphragm or Condom (Y/N) Wearing Rubber Gloves (Y/N) Have you experienced an unexplained anaphylactic episode? (For example: rapid heart, swelling of your throat and respiratory distress all at the same time) (Y/N) If yes, which one? FOOD ALLERGY Are you allergic to any of the following? IF so, indicate which ones and the reaction. Bananas/Avocados Kiwi Fruit/Chestnuts ** Nursing** If patients answers yes to BOTH a LATEX ALLERGY and ANY of the above questions were answered yes-note LATEX ALLERGY on the front of the chart. ASA CLASSIFICATION I II III IV V PHYSICIAN SIGNATURE DATE

PLAN OF TREATMENT Pain Clinic Patient Intake Form Please Shade on the drawing below where you feel pain.

Intake Form Completed Per Patient Responses Date: Nurse Signature

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