Legacy Pain Management Center New Patient Questionnaire

Similar documents
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.

PAIN INFORMATION SHEET

DOB Age Sex Weight Height Right Handed Left handed

Chayapathy Jollu, MD Board Certified in Physical Medicine and Rehabilitation Patient Initial Pain Questionnaire

Initial Pain Questionnaire

COMPREHENSIVE REHABILITATION PAIN QUESTIONNAIRE. Date of Visit. Statement of Problem: Date of Injury/onset of condition: Date of birth: Age

Spine & Pain Center. On the diagram, shade the area where you feel pain. Put an X on the area that hurts the most.

UnityPoint Clinic - Cardiology

New Patient Intake Form. Please List All Current Medications. Please shade in the areas where you have pain

NEW PATIENT INFORMATION SHEET

* CC* PATIENT QUESTIONNAIRE

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C

New Patient Pain Evaluation

COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:

NEW PATIENT QUESTIONNAIRE

Name: Date: Street Address: Referring Physician: How long have you had your current problem?

HD CLINIC MEDICAL HISTORY FORM

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

Aspire Pain Medical Center

Pain Drawing. Name: Today s Date: How were you referred to the office: Visual Analog Scale

NEW PATIENTS' INFORMATION SHEET

Referring Physician/Therapist. Primary Care Physician. Reason for Visit

New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire

Other physician #1. #(p) List any allergies to medications. Please list below all other current medical conditions or previous surgeries

NEW PATIENT INFORMATION FORM

Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week

New Patient Pain History Form

Providence Medical Group

SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD

PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

Salt Lake Orthopaedic Clinic Initial Visit Form

SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE

Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?

Please describe, in detail, when the symptoms began:

Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,

MCKAY UROLOGY LINCOLNTON OFFICE PATIENT HISTORY FORM

Amarillo Surgical Group Doctor: Date:

NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight:

GUPTA SPORTS & SPINE CENTER

MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History

MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)

Richard Senysyzn, MD Psychiatry for Adults 1260 River Acres Drive New Braunfels, TX , Fax. (888)

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

Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.

Psychiatric Evaluation Intake Form

Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio

DIVISION OF CARDIOLOGY

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

Medical History Form

History & Review of Systems Screening. Medical History

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.

Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX Phone (903) Fax (903)

PAIN SOLUTIONS NEW PATIENT QUESTIONNAIRE

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency

PATIENT HISTORY FORM

Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency.

Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)

SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

NEW PATIENT VISIT QUESTIONNAIRE

History of Present Illness Please answer the following questions

ASSIGNMENT OF BENEFITS

NEW PATIENT HEALTH HISTORY

Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain 0 = Numbness / = Aching * = Pins & Needles

Southern Interventional Pain Center New Patient Evaluation Form

Providence Neurosurgery PATIENT INFORMATION SHEET

FAMILY MEDICINE New Patient Medical History Form

Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State

DANA COKER KINGDON, PA

PATIENT HISTORY FORM

Coastal Digestive Diseases, P.C. MA New Pt Ht

HEALTH HISTORY. Pharmacy: Phone# Fax# Current Medications: Dosage: Frequency:

Date of Visit / / Date of Birth / / Age

Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY

Osher Center for Integrative Medicine Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician:

Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire

BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM

Patient Information. Legal Name: First Middle Last. Street City State Zip

PATIENT DEMOGRAPHIC INFORMATION

PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.

NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE

Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a

NEW PATIENT INFORMATION

NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

Please fill out this form as completely as possible. This information will determine how we treat your pain problem.

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

Broward Oncology Associates, P.A. PATIENT INFORMATION

Allina Health United Lung and Sleep Clinic

New Patient Evaluation

Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire

Initial Pain Management Patient Questionnaire

2. Have your symptoms affected your ability to carry out your daily activities? YES NO

Transcription:

Legacy Pain Management Center New Patient Questionnaire Please complete this form prior to your visit to allow us to make the best use of our time together. Primary Care Provider: Referring Physician: Other providers you currently see: Pain History 1. What is the diagnosis of your pain? (If known) 2. How did your pain begin? 3. When did your pain problems begin? (date of injury or your age when pain began) 4. Where is the pain? (Shade pain areas on the diagram below). Draw an arrow to the WORST area. Is the pain: (please check those that apply): [ ] aching [ ] burning [ ] constant [ ] pulsing [ ] shooting [ ] sharp [ ] stabbing 5. Do you have pain at all times? Y N (circle one) 6. What time of day does your pain bother you most? 1

7. On average, how severe is your pain from 0 to 10, with 0 being NO pain and 10 being WORST pain imaginable? 8. Do you have any Where? weakness? 9. Do you have any numbness? Where? 10. What makes your pain worse? 11. What makes your pain better? 12. What medications do you currently use for pain? (Please include dosage and frequency). Pain Treatment History 1. Circle all pain medications you have tried in the past: Name of Medication (Brand Name) Still Taking? Reason for stopping hydrocodone (Vicodin, Norco) oxycodone (Percocet, Oxycontin) methadone hydromorphone (Dilaudid) tramadol (Ultram) codeine (Tylenol #3) fentanyl patch (Duragesic) morphine (MSContin, Kadian) oxymorphone (Opana) cyclobenzaprine (Flexeril) methocarbamol (Robaxin) tizanadine (Zanaflex) metaxalone (Skelaxin) carisoprodol (Soma) gapapentin (Neurontin) pregabalin (Lyrica) duloxetine (Cymbalta) venlafaxine (Effexor) amitriptyline (Elavil) buprenorphine/naloxone (Suboxone) 2

2. Circle all other therapies you have tried: Pain therapies tried: Past? Current? Were they helpful? (Yes/No) Physical therapy Counseling Injections Other: Review of Systems Check any of the following symptoms you have experienced in the past month: Constitutional Cardiac Musculoskeletal Neurological, cont. Fatigue Chest pain Joint Pain Seizures Fevers Swelling Back Pain Tremors Joint swelling Weakness Eyes Gastrointestinal Muscle Pain Itching Constipation Mood Light sensitivity Diarrhea Skin Decreased concentration Vision changes Nausea Color change Depression Vomiting Rash Hallucinations Respiratory Wounds Anxiety Shortness of Breath Genitourinary Sleep difficulty Wheezing Problems urinating Neurological Considered suicide Incontinence Headaches Frequent urination Numbness Medical History 1. List ALL other MEDICATIONS and dosage (VERY IMPORTANT): 2. List any allergies to medications: 3. List all surgeries and their dates, if known: 4. Have you ever been diagnosed with sleep apnea? If yes, do you use a CPAP mask at night? 3

Do you use oxygen at night? Social History 1. Do you use tobacco? If yes, how much and when did you start? If no, have you in the past? 2. Do you drink alcohol? If yes, how much and how often? 3. Do you currently use any illicit substances? 4. Do you have a history of substance abuse? If yes, what substance and when was last use? 5. Marital status: [ ] Married [ ] Never married [ ] Live with spouse/partner [ ] Widowed [ ] Divorce/separated 6. Do you live alone or with others? [ ] Alone [ ] With others 7. Are you currently employed? [ ] Yes, how many hours per week and where? [ ] No, when did you last work? 8. Are you currently on disability? 9. Are you currently involved in a disability or legal claim? Psychological History 1. Have you even been diagnosed with anxiety, depression, panic attacks, or any other psychological condition? If yes, what/when? 2. Are you under the care of a mental health professional? If yes, who? 3. Do you have a history of prior physical or sexual abuse or other traumatic experiences? 4. Are you bothered by little interest or pleasure in doing things? 5. Have you been feeling down, depressed, or hopeless? 4

Family History Relationship Status Arthritis Cancer Chronic Pain Depression Diabetes High Blood Pressure High Cholesterol Obesity Substance Abuse Migraine Mother Alive Deceased Father Alive Deceased Maternal Grandmother Alive Deceased Maternal Grandfather Alive Deceased Paternal Grandmother Alive Deceased Paternal Grandfather Alive Deceased Other: Alive Deceased Thank you for taking the time to fill out this questionnaire! 5

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback