ADVANCED PAIN MANAGEMENT

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Transcription:

ADVANCED PAIN MANAGEMENT Patient Name Date Date of Birth Sex Marital Status Phone Numbers: Home ( ) Work ( ) Cell ( ) Street City State Zip General Health Review Medical History (such as heart disease, stroke, cancer, arthritis, diabetes, hypertension, as well as Psychiatric illnesses, etc.) Surgical History (unrelated to pain; such as appendectomy) Surgical History (related to pain; such as laminectomy) Allergies (include side effects from previous medications, such as gastritis, nausea, constipation, etc.) Intolerances (include side effects from previous medications, such as gastritis, nausea, constipation, etc.) Current Medications (include vitamins and birth control pills, if applicable) 1

Do you have any of the following? (Circle all that apply) Headaches Stomach Chest Vision Problems Nausea Shortness of Breath Hearing Problems Vomiting Urinary Problems Dizziness Constipation Rashes Difficulty Swallowing Diarrhea Swollen Joints Chronic Fatigue Domestic Situation With whom do you live? Are there any substance abuse issues in the household? If yes, please explain Any physical abuse issues? Explain: Are you able to take care of yourself? If not, please enter name of caregiver Work History Job Years worked Why did you leave? Legal Matters Are you presently involved in a lawsuit? If yes, please explain. Substance Use Which of the following drugs or substances, if any, have you used in the past? (Circle all that apply) Next to each drug or substance that you ve circled, indicate if you used it occasionally ( O ), frequently ( F ), or continuously ( C ). Alcohol Barbiturates Cocaine Heroin Amphetamines Marijuana Other Other Other (specify) (specify) (specify) Are you presently using any of the drugs or substances below? (Circle all that apply) Next to each drug or substance that you ve circled, indicate if you use it occasionally ( O ), frequently ( F ), or continuously ( C ). Alcohol Barbiturates Cocaine Heroin Amphetamines Marijuana Other Other Other (specify) (specify) (specify) Do you presently smoke cigarettes or use tobacco in any form? If not, did you ever smoke cigarettes or use tobacco in any form? How much packs do (did) you smoke a day? For how many years? 2

Reason for visit: History of present illness: Location Quality (How severe is the pain/problem?) (Example normal vs abnormal color, activity, etc.) Severity Duration (How severe is pain on scale of 1-10?) (How long have you had this pain/problem? When did it start?) Timing Context (Does this pain/problem occur at a specific time?) (Where were you at the onset of this pain/problem?) Associated signs/symptoms Modifying factors (What other associated problems are you having?) (What makes the pain/problem worse or better?) Medical History: *Patient Medical History: Diabetes Hypertension Cancer Stroke Heart Trouble Arthritis/Gout Convulsions Bleeding tendency Acute Infections Venereal Diseases Heredity Defects *Patient Social History: Marital Status: Single: Married: Seperated: Divorced: Widowed: Use of Alcohol: Never: Rarely: Moderate: Daily: Use of Tobacco: Never: Previosly quit: Current packs per day: Use of Drugs: Never: Type/Frequency: Excessive Exposure at home/work: Fumes: Dust: Solvents: Air-borne particles: ise: Occupation/Work History: *Family Medical History: Age Diseases If Deceased, Cause of Death Father Mother Siblings Spouse Children 3

Review of Systems: Please indicate any personal history: CONSTITUTIONAL SYMPTOMS Good general health lately Recent weight change Decreased appetite Fever/Night sweats Fatigue/Weakness. Headaches. EYES Eye disease or injury. Wear glasses/contact lenses. Blurred or double vision.. Glaucoma/cataracts.. EARS/NOSE/THROAT Hearing loss or ringing Earaches or drainage.. Chronic sinus problems or rhinitis. sebleeds Mouth sores Sore throat or voice change. Swollen glands in neck.. CARDIOVASCULAR Heart trouble Chest pain or angina pectoris. Palpitation.. Shortness of breath w/walking or lying flat Swelling of feet, ankles, or hands. RESPIRATORY Chronic or frequent coughs.. Spitting up blood. Shortness of breath. Asthma or Wheezing.. GASTROINTESTINAL Loss of appetite Change in bowel movement.. Nausea or vomiting. Frequent diarrhea ful bowel movements or constipation... Rectal bleeding or blood in stool.. Abdominal pain Peptic ulcer (stomach or duodenal). GENITOURINARY Frequent urination Burning or painful urination Awaken at night to urinate Blood in urine Change in force or strain when urinating Incontinence or dribbling Sores or discharge Kidney stones Sexual difficulty.. Male testicle pain/lumps.. Female pain with periods Female irregular periods. Female vaginal discharge. Female - # of pregnancies Female - # of miscarriages.. Female date of last pap smear.. Reviewed By: Date: ENDOCRINE Glandular or hormone problem.. Thyroid disease... Diabetes(insulin or noninsulin).. Excessive thirst or urination.. Heat or cold intolerance MUSCULOSKELETAL Joint Joint stiffness or swelling... Weakness of muscle or joints.. Muscle pain or cramps... Back pain.... Difficulty walking.. INTEGUMENTARY (skin, breast) Rash or itching Change in skin color Change in hair or nails... Varicose veins Breast pain Breast lump.. Breast discharge... NEUROLOGICAL Frequent or recurring headaches Lightheaded or dizzy. Convulsions or seizures. Numbness or tingling sensations Tremors. Paralysis Stroke Head injury PSYCHIATRIC Memory loss or confusion Nervousness Depression Insomnia.. HEMATOLOGIC/LYMPHATIC Slow to heal after cuts. Bleeding or bruising tendency Anemia Phlebitis Past transfusion. Enlarged glands ALLERGIC/IMMUNOLOGIC History of skin reaction or other adverse reactions: Penicillin or other antibiotics Morphine, Demerol or other narcotics vocain or other anesthetics. Aspirin or other pain remedies Tetanus antitoxin or other serums Iodine, merthiolates or other antiseptics.. Other drugs/medications: Known food allergies: Environment allergies: 4

Primary Care Physician Address City State Zip Phone If Workman s Compensation, list case worker Address City State Zip Phone Would you like letters sent to other physicians? If yes, please list name and address Name Address City State Zip Phone Emergency Contact Relationship Address City State Zip Telephone numbers: (Home) (Work) Initial Assessment By answering the following questions, you will help your physician better understand and treat your pain. When and how did your pain problem start? As far as you know, what is the cause of your pain (ie, the diagnosis)? What doctors have you seen? When did you see them? What did they do? (for example: Doctor did physical exam, Ordered tests, prescribed medication) Doctor s Name Month/Year Seen What Was Done What tests and studies have been done? (for example: MRI, CT-Scan, X-Rays) Month/Year Done 5

List the body sites where you experience pain and circle the words that best describe the pain at that site. Also, indicate The intensity of the pain and those things that make your pain better or worse. Use a separate sheet for each body site. Body Site Circle the words that describe you pain. Aching Sharp Penetrating Throbbing Tender Nagging Shooting Burning Numb Stabbing Exhausting Miserable Gnawing Tiring Unbearable Intermittent Continuous Circle the number that best describes your pain at its worst during the last month. Circle the number that best describes your pain at its least during the last month. Circle the number that best describes your pain on average during the last month. Circle the number that best describes your pain as it is right now. What sorts of things make this pain feel better (for example: heat, rest, medicine)? What sorts of things make this pain feel worse (for example: walking, standing, lifting)? 6

On the diagram below, shade the areas where you feel pain. X the areas the hurt the most. What pain treatments or medications are you receiving now or have received in the past? (For example, pain medications, physical therapy, acupuncture, TENS, etc.) Circle the number next to the treatment to signify the amount of pain relief that treatment is providing or has provided. Treatment or Complete Check if Medication Relief Relief Receiving w 7

Circle the numbers below that best describe how pain has interfered with your daily functioning. General Activity Mood Walking Ability rmal Work Routine Relations With Other People Sleep Enjoyment of Life Ability to Concentrate Appetite Cz0020What level of pain do you think you could function with on a daily basis? 8

The attached information was reviewed with the patient by: 9

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