MICHIGAN INTERVENTIONAL PAIN ASSOCIATES

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MICHIGAN INTERVENTIONAL PAIN ASSOCIATES Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and REPORTS of any X- rays, MRI or Cat scans. Patient s name: Age: Appointment date: Birthdate: Arrival time: Referring Physician Address/Phone Number Primary Physician Address/Phone Number IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT. In order to facilitate your care, it is essential you complete all attached forms. While we understand this may be difficult, it is important we learn as much about you as we can. Some questions may seem unrelated to your problem, but pain is a very complex issue, so please complete this document to the best of your ability. Upon your arrival, a member of MIPA will review this questionnaire with you. You will then be evaluated by a physician. Sam George DO Sharon Minott MD Steven Wiener MD 1

PLEASE SHADE IN THE AREA WHERE YOUR PAIN OCCURS HISTORY OF PRESENT ILLNESS Under what circumstances did your pain begin? (Check all that applies) [ ]accident at work [ ]accident at home [ ]work related [ ]pain just began [ ]motor vehicle accident [ ]following surgery [ ]following illness If your pain began with a work related accident, please provide the following: Place of employment Date of injury Type of work What were you doing when the pain occurred On the scale below, place a mark on the graph to represent the severity of your pain. 0 is no pain and 10 is the worse pain imaginable Currently, what is your pain score?!--------!--------!--------!--------!--------!--------!--------!--------!--------!--------!--------! 0 1 2 3 4 5 6 7 8 9 10 What is the highest your pain score that you have ever had?!--------!--------!--------!--------!--------!--------!--------!--------!--------!--------!--------! 0 1 2 3 4 5 6 7 8 9 10 What is the lowest pain score that you have ever had?!--------!--------!--------!--------!--------!--------!--------!--------!--------!--------!--------! 0 1 2 3 4 5 6 7 8 9 10 2

Duration: How long have you had this pain problem? yrs /months/days When did you first notice your pain? Timing of your pain (when is it the worst): [ ]First thing in the morning [ ]Later in the morning [ ]Afternoon [ ]Evening [ ]Bedtime [ ]Pain is ALWAYS the same Quality of your pain (how would you best describe your pain: [ ]Burning [ ]Sharp [ ]Aching [ ]Throbbing [ ]Shooting [ ]Other Associated signs and symptoms: [ ]Numbness [ ]Tingling [ ]Pins and Needles [ ]Weakness [ ]Coldness [ ]Swelling [ ]Muscle Spasm [ ]Tightness [ ]Skin Discoloration [ ]Bowel or Bladder Problems. What activities increase your pain: [ ]Sitting [ ]Standing [ ]Lying [ ]Worry/Stress [ ]Driving [ ]Walking [ ]Weather [ ]Time of Day [ ]Activities [ ]Sex Which of the following decrease your pain: [ ]Rest [ ]Lying [ ]Sitting [ ]Standing [ ]Drug/Alcohol [ ]Physical Activity [ ]Time of Day Please indicate which of the following you have tried if any. Was it helpful? How long was it helpful Acupuncture Biofeedback Chiropractor Heat Hypnosis Ice Illicit (street drugs) Massage Prescribed pain medicine Physical therapy Where did you go? Date of last treatment / use Nerve blocks Therapy/counseling Surgery Steroid treatment TENS 3

Please indicate which of the following you have tried if any. Procedure/injection Relief How long Do you currently use or have you ever used- Walker Cane Wheelchair MEDICAL HISTORY Have you had Y N Comments Have you had Y N Comments asthma/emphysema angina hypertension heart attacks congestive heart failure MVP or valvular disease diabetes arthritis depression sleep apnea REVIEW OF SYSTEMS Have you had Y N Comments Have you had Y N Comments weight gain or loss constipation fevers/chills issues with eyes/vision issues with nose/throat problems breathing bowel Incontinence bladder incontinence bone/muscle pain snoring chest pain thyroid trouble bleeding/bruising stomach pain Females only First day of your last menstrual period Are you periods normal? Any abnormal vaginal / breast discharge? Number of pregnancies Number of deliveries 4

PAST SURGICAL HISTORY Please list all the operations you have undergone, including the year they were performed. 1. 2. 3. 4. 5. MEDICATIONS Please list all the medications you are currently taking, including the dosage. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. What pain medications have you tried in the past for your pain? DRUG ALLERGIES/SENSITIVITY REACTION 1. 2. 3. 4. 5. Environmental / Food Allergies: (mold, dust, pollen, cats, dogs, eggs ) 1. 2. 3. 4. 5

PERSONAL HABITS: Do you smoke? how much per day If no, are you a previous smoker? Do you drink alcohol? If yes, how much? Have you ever had a problem with drugs or alcohol? Do you have a history of illicit drug use? How many caffeinated beverages do you consume daily How often do you see a doctor? [ ]3 or more times per month [ ]1 2 times per month [ ]less than once a month SOCIAL/OCCUPATIONAL HISTORY Marital Status: Single Married Widowed Divorced Separated Remarried Spouse s name Number of children? Ages? Who shares your home? Occupation How long at this position? Brief description of job duties Work Status: Full Time Part Time Student Disabled Unemployed Retired If disabled, date last worked If working less than full time is pain the reason? If you had no pain would you return to work? Has your employer been helpful and understanding of your problem? yes or no? What would you hope to be the end result of this evaluation? (Please circle) Medical diagnosis / Recommendations for surgery / Recommendations for medications Recommendations for rehabilitation If you are treated here, what are the results you HOPE for? (Please circle) Pain reduction / Increased recreation / Improved emotional well- being Increased socialization / Return to work If you are treated here, what are the results you EXPECT? 1. 2. 3. 6

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