1 Today s Date: Robert J. Brownsberger, M.D., PC New Patient Paperwork Your Name: Date of Birth: SS#: Email: Race/Ethnicity: Primary Language: Mailing address: Home Phone: Cell Phone: Preferred Pharmacy: Emergency Contact Name/Phone #: Relationship: Who is your Primary Care Provider? Were you referred to our clinic by another physician? Yes Name of Referring Provider: Primary Insurance name: Insurance ID # Group # Secondary Insurance name: Insurance ID # Group # Policy holders name (if different from patient) DOB Relation: No Onset of Systems and Reason for Visit Use the diagram below to indicate the location and type of your pain. Mark the drawing with the following letters that best describe your symptoms: N umbness P ins and Needles A ching S tabbing B urning What is your current pain level? What is your worst level of pain level?
2 Where is your worst area of pain located? Does the pain radiate? If yes, where? Additional areas of pain When did the pain begin? What caused your current injury? Was the pain or injury due to a motor vehicle accident, personal injury or work injury? How did your current pain episode begin? Gradually Suddenly Since your pain began, has your pain Increased Decreased Stayed the Same Check all that describe your pain TODAY - Aching Hot/Burning Numb Shooting Spasming Stabbing/Sharp Tingling/Pins and Needles What word best describes the frequency of your pain? Constant Intermittent When is your pain at its worst? Mornings During the Day Evenings Middle of Night What makes your pain worse? Sitting laying Standing Walking What makes your pain better? Sitting laying Standing Walking Diagnostics Prior to Visit MRI of the Date: Facility: X-ray of the Date: Facility: CT scan of the Date: Facility: EMG/NCV study Date: Facility: I HAVE NOT HAD ANY DIAGNOSTIC TESTS PERFORMED FOR MY CURRENT PAIN COMPLAINTS Pain Treatment History Treatment No Relief Moderate Relief Excellent Relief Biofeedback Bracing Chiropractic Decompression Therapy Epidural Steroid Injection Home Exercise Program Medial Branch Blocks Medications, please check which ones below - Topical Cream Anti-inflammatories Muscle Relaxants
3 Nerve Pain Medications Cymbalta Lyrica Neurontin Physical Therapy Radiofrequency Ablation Spine Surgery Spinal Column Stimulator TENS Unit Trigger Point Injections Other Treatments, include any opiates tried: I HAVE NOT HAD ANY PRIOR TREATMENTS FOR MY CURRENT PAIN COMPLAINTS Medication History Are taking a prescribed blood-thinner or aspirin, if so, which one? Please list ALL medications you are currently taking. Attach an additional sheet if required. Medication Name Dose Medication Name Dose Frequency Frequency 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. Activity Are you able to exercise? Yes No How often do you exercise? Once a week Twice a week Three times a week Four times a week Five times a week More: If so, what exercise do you perform? Bicycle Cardio Strength Swimming Walking Are you currently pregnant? Yes No
4 Allergies Please list ALL medications that you have an ALLERGY to. Medication Name 1. 2. 3. 4. 5. List reaction if ingested Reaction Do you have an allergy to Iodine? YES NO Do you have an allergy to tape? YES NO Do you have an allergy to Latex? YES NO Surgical History I HAVE NOT HAD ANY PAST SURGERIES Joint Surgery Shoulder Hip Knee Spine/ Back Surgery Discectomy (levels) Laminectomy Spinal Fusion (levels) Please list any other surgeries you have had: Family History I AM ADOPTED (No Medical History Available) I HAVE NO SIGNIFICANT FAMILY MEDICAL HISTORY Anxiety/Depression Mother Father High Blood Pressure Mother Father Cancer Mother Father Substance Abuse Mother Father Diabetes Mother Father
5 Social History Alcohol Use: Never Drinks Alcohol Social Alcohol Use History of Alcoholism Smoker or Tobacco Use: Never Former User Current User Marijuana Use: Never Former User Current User Medical Marijuana Card Holder Drug Use: Never Used I Have a CURRENT or PAST history of illegal drug, alcohol or narcotic abuse, list: Medical History Cardiovascular/Respiratory: Asthma Emphysema/COPD Tuberculosis Valley Fever High Blood pressure Swelling in the Feet Head/ Eyes/Ears/Nose/Throat: Glaucoma Headaches Head injury Hyperthyroidism Hypothyroidism Migraines Neuropsychological Alzheimer Disease Anxiety/Depression Bipolar Disorder Epilepsy Multiple Sclerosis Paralysis Peripheral Neuropathy Schizophrenia CRPS/Reflex Sympathetic Dystrophy Musculoskeletal: Amputation/Phantom Limb Pain Bursitis Fibromyalgia Joint injury Osteoarthritis/Osteoporosis Rheumatoid Arthritis Vertebral Compression Fracture General Medical Cancer- Type Diabetes Type HIV/AIDS
6 Review of Systems Constitutional: Chills Difficulty Sleeping Fatigue Fevers Night Sweats Eyes Recent Visual Changes Ears/Nose/Throat/Neck: Difficult hearing Earaches Hayfever/Allergies Nosebleeds Ringing in ears Cardiovascular/Respiratory: Chest Pain Cough Difficulty Breathing Fainting Gastrointestinal: Constipation Dark and Tarry Stools Diarrhea Nausea/Vomiting Genitourinary/Nephrology: Blood in Urine Involuntary Urination Loss of bowel control Painful urination Pelvic Pressure Musculoskeletal: Back Pain Joint Pain Neck Pain Neuropsychological: Dizziness Headaches Instability When Walking Numbness/Tingling Weakness Psychiatric: Anxiety/Stress Depressed Mood Suicidal Thoughts Suicidal Planning Oswestry Questionnaire / Do not score yourself PAIN INTENSITY Score: LIFTING Score: 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 pain imaginable at the moment I can lift heavy weights without extra pain I can lift heavy weights but it gives extra pain Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently place 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 very light weights I cannot lift or carry anything at all PERSONAL CARE Score: WALKING Score: I can look after myself normally without causing extra pain Pain does not prevent me from walking any distance Pain prevents me from walking more than 1 mile
7 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 manage most of my selfcare I do not get dressed, I wash with difficulty and stay in bed Pain prevents me from walking more than ½ mile Pain prevents me from walking more than 100 yards I can only walk using a stick or crutches I am in bed most of the time SITTING Score: SEX LIFE Score: I can sit in any chair as long as I like I can only sit in my favorite chair as long as I like Pain prevents me 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 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 nearly absent because of pain Pain prevents any sex life at all STANDING Score: SOCIAL LIFE Score: 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 form standing for more than 30 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all 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 apart from limiting my more energetic interests eg, sports Pain has restricted my social life and I do not go out often Pain has restricted my social life to my home I have no social life because of pain SLEEPING Score: TRAVELING Score: My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours of sleep Because of pain I have less than 4 hours of sleep Because of pain I have less than 2 hours of sleep Pain prevents me from sleeping at all I can travel anywhere without pain I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys over 2 hours Pain restricts my traveling of less than 1 hour Pain restricts me to short and only necessary traveling of less than 30 minutes Pain prevents me from traveling except to receive treatment
8 Family History of Substance Abuse: Alcohol Illegal Drugs Prescription Drugs Personal History of Substance Abuse: Alcohol Illegal Drugs Prescription Drugs Mark Each that Applies item Score If Female 1 2 4 OFFICE USE ONLY Item Score if Male Your Age (Mark box if 16-45) 1 1 Personal History of Preadolescent Sexual Abuse: 3 0 Personal History of Psychological Disease: Attention Deficit Disorder, OR Obsessive Compulsive Disorder, OR Bipolar, OR Schizophrenia 3 4 5 2 3 3 4 3 4 5 2 Depression 1 1 None of the above apply to me TOTAL Consent for Treatment I certify that the above information is accurate, complete and true. I authorize Robert J. Brownsberger, M.D., PC and any associates, assistants, and other health care providers it may deem necessary, to treat my current condition. I understand that no warranty or guarantee has been made of a specific result or cure. I agree to actively participate in my care to maximize its effectiveness. In the event that I am asked to provide a urine sample, I voluntarily seek laboratory services and hereby consent to provide a urine sample, as requested. I have the right to refuse specific tests, but understand this may impact my pain management treatment. This agreement can be revoked by me at any time with written notification and is valid until revoked. I give my consent for Robert J. Brownsberger, M.D., PC to retrieve and review my medication history. I understand that this will become part of my medical record. Signed: Date: Patient or Guardian or Patient Representative: Printed Name: