INITIAL PAIN EVALUTION QUESTIONNAIRE We are interested in understanding more about your pain. Please help us by filling out this questionnaire. Please bring the completed questionnaire with you for your first appointment. Name: Date of Birth: Date: Primary Care Physician: Referring Physician (if different): Name:, Name:, Address: Address: Phone: Phone: 1. Where is the location of your pain? Please use the diagram below to indicate where your most painful areas are located. Shade in these areas darkly and shade in your less painful areas IiglJtly. ~Q ~ I -- ft' L~L~ R Q~ ~;Fi\ RIO~ Page 11
Where is the location of the pain? Please use the diagram below to indicate where your most painful areas are located. Mark these areas appropriately per index below. Right teft.,/' Index: xxx PAIN 000 NUMBNESS -WEAKNESS +++ CRAMPING Page 12
2. When did your pain problem begin, or if your pain is related to a specific injury, what date did the injury occur? Month: Day: Year: 3. How did your pain first start? (Car accident? Fall? Job related injury? Etc.) 4. Please circle the level of your pain on a scale of 0 (no pain) to 10 (worst pain imaginable) for the following: PRESENT level of pain: 0 1 2 3 4 5 6 7 8 9 10 ( pain) (Worst pain imaginable) Worst level of pain you've had: 0 1 2 3 4 5 6 7 8 9 10 ( pain) (Worst pain imaginable) Using the same scale, what level of pain is ACCEPTABLE for you? o 1 ( pain) 2 3 4 5 6 7 8 9 10 (Worst pain imaginable) 5. How often do you have pain? Please circle one. Constant Intermittent (Occasionally) 6. Describe your pain. Is it dull, sharp, shooting/stabbing, burning, arching, or other? 7. Have you experienced any of the following symptoms? Please indicate by circling: Numbness Tingling Weakness Coldness Spasm or Tightness Page I 3
8. Are there things that influence your pain? Please check all that apply. TREATMENT WORSENS RELIEVES NO DIFFERENCE COMMENTS Exercise Walking Massage Sitting Standing Touch Heat Pack Ice Pack Temperature(hot) Temperature(cold) Weather Bright lights Eating Alcohol Emotional Stress Urination Bowel Movement ise People Music Sleeping Sexual Activity Menstrual Cycle Medicines Rolling in Bed Moving from sitting to standing Stairs Other Page 14
9. Are you currently working? Please circle answer Yes Retired If yes, describe you occupation: 10. If you are not working, has pain forced you to stop working? Please circle answer Yes 11. If you are not working presently, what type of work did you use to do? 12. Are you being treated under Worker's Compensation? Please circle answer Yes 13. Are you currently receiving or applying for disability benefits? Please circle answer Yes 14. Are there areas of your life that have been affected by your pain problem? circle all that apply Sleep Appetite Relationships Work Finances Physical Activity Use of Alcohol Use of Recreational Drugs Emotions Concentration Other, Describe 15. What medications have you tried in the past? 16. What best describes your present use of pain medication? Please circle one Definitely increasing Increasing slightly Same as always Decreasing slightly Definitely decreasing t applicable Page I 5
17. What treatments have you had in the past for you pain? Please check all that apply and indicate whether it was helpful or not helpful. TREATMENT HELPFUL NOT HELPFUL COMMENTS Surgery Nerve block Steroid injection Acupuncture Trigger point injection TENSunit Heat/ Ice treatment Biofeedback Hypnosis Relaxation training Counseling Physicaltherapy Traction Chiropractic treatment Occupational therapy Other (explain) 18. Are you involved in any legal action related to your pain problems or considering it in the future? Please circle answer and describe if applicable: Yes 19. Please circle any of the following medical conditions you now have or have had in the past: Diabetes Cancer Heart Problems Respiratory Problems (e.g. asthma, emphysema) Arthritis Ulcer Kidney Problems Bleeding Problems Infectious Disease Seizures High Blood Pressure Neurogenic Disease Other: Page I 6
20. Please list all past surgeries and hospitalizations: If more room is needed, use the back side of this paper DATE REASON FOR DOCTOR FACILITY HOSPITALIZATION 21. Have you had any of the following tests performed within the past 24 months? TEST DATE FACILITY WHERE TEST WERE DONE X-ray film CT Scan MRI Laboratory EMG Myelogram Other 22. Please list all you current medications, including "over the counter medications" Below: If more room is needed, use the back side of this paper. MEDICATIONS STRENGTH(how TOTAL DAILY IS IT EFFECTIVE? ORDERING many milligrams) DOSE (yes, no, or somewhat) PHYSICIAN 23. Please list all of your ALLERGIES: Page I 7
24. What is your current marital status? Please circle one: Married Single Divorced/Separated Widowed Living with Significant Other 25. Do you Smoke? Yes If yes, how may packs per day? 26. Do you drink alcoholic beverages? Yes If yes, how often do you drink and how much? 27. Do you use recreational drugs: Yes If yes, please describe: 28. Have you ever (now or in the past) had a problem with drugs or alcohol abuse? Yes If yes, please describe: 29. What is the highest level of education you have received? 30. Please list the names and ages of all the people that live with you: 31. What illnesses run in your family? 32. Have you ever been seen by another pain specialist? Yes Ifso,where? 33. Have you ever been concerned about the amount of pain medication you take? Please circle one answer: Yes 34. Please provide any other information pertinent to your current pain: Page 18
35. Do you have a history of or experience any of the following symptoms or problems Please circle YESor for each problem. Yes Blurry vision Yes Glaucoma Yes Ringing in your ears Yes Clenching your teeth Yes Tightness in your chest or chest pain Yes Heart disease or irregular heart beats Yes Need to sleep sitting up in order to get your breath Yes Difficulty breathing Yes Emphysema or asthma Yes Abdominal pain Yes Stomach ulcers or gastritis Yes Irregular bowel Yes Irritable bowel disease Yes Blood in your stool Yes Pelvic pain Yes Frequent urination Yes Inability to urinate Yes Seizures Yes Frequent headache Yes Episodes of blacking out or passing out Yes Unexplained fevers Yes Excessive fatigue Yes Difficulty falling or staying asleep Yes Rashes Yes Rheumatoid arthritis, lupus, sarcoid or scleroderma Yes Diabetes Yes Thyroid problems Yes Depression Yes Anxiety Page I 9
36. Since your pain condition began, please list the name(s) of the following people you have consulted for treatment and pain relief. SPECIALIST NAME ADDRESS PHONE Acupuncturist Allergist Anesthesiologist Cardiologist Chiropractor Clergyman Dentist Dermatologist Ear, se or Throat Endocrinologist Faith Healer Primary Care/Family Hypnotist Internal Medicine Neurologist Obstetricia njgyn Oncologist Ophthalmologist Orthopedist Osteopath Plastic Surgeon Proctologist Psychiatrist Psychologist Radiation Oncologist Rheumatologist Surgeon Page 110