PAIN CLINIC PATIENT INTAKE FORM

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PAIN CLINIC PATIENT INTAKE FORM PAITNET INFORMATION Name: Date of Birth: Health Card# Version Code: Gender: Male Female Address: Home Phone: City: Postal Code: Cell Phone: Work Phone: Who is your primary care provider (Physician/NP, etc.): Insurance Provider: As a professional courtesy, we would like to keep your primary care provider up to date regarding your injury or treatment. Is it Ok to provide them with a consultation note and updates related to your injury?: YES NO Who may we contact in case of an emergency? Relationship: Phone 1: Phone 2: Please list below all individuals with whom we may talk to about your health concerns: Name: Relationship: Name: Relationship: Do you have any allergies? (Medications, foods, environmental) Are you currently taking any medications (prescription or over the counter, or supplements?) MEDICAL HISTORY Weight Loss / Gain Loss of Energy Unusual Fatigue Headaches Severe Migraine Dizziness or Fainting Decreased Hearing Ringing in Ears(s) Failing Vision Blurred or Double Vision Eye Pain Frequent Ear Infections Glaucoma Cataracts Sinus Pain Frequent Sore Throats Teeth/Gum Pain/Bleeding Hoarseness Chronic Cough Hay Fever Allergies Pneumonia / Pleurisy Bronchitis / Emphysema (COPD) Asthma / Wheezing Shortness of Breath Chest Pain or Tightness Heart Murmur Irregular Pulse Past and Present Medical History Palpitations High Cholesterol / Fat Swollen Ankles Calf Pain (while walking) Varicose Veins / Phlebitis Loss of Appetite (Recent) Difficulty Swallowing Indigestion or Heartburn Frequent Nose Bleeds Difficulty Sleeping Eczema Insomnia Peptic Ulcer Abdominal Pains Gall Bladder Troubles Jaundice / Hepatitis Change in Bowel Habits Diarrhea Constipation Bowel Polyps Crohn s or Colitis Hernia Hemorrhoids Frequent Urinary Tract Infections Anemia Urinary Painful, Bloody, No Control Decrease in force or flow of urine Kidney Stones

STD s / Genital Warts Urethral Discharge Circulatory Problems Bruise Easily Cancer (Type: ) Diabetes Excessive Thrust Thyroid Disease Seizures / Convulsions Stroke Tremor/Hands Shaking Muscle Weakness Numbness / Tingling Sensations Arthritis / Rheumatism Back Pain Frequent Bone Fracture/Joint Injury Gout Osteoporosis Foot Pain Cold/Numb Feet Rashes Hives Psoriasis Drug Abuse Depression Nervousness Memory Loss Phobias Moodiness Stress Excessive Mental Illness Chicken Pox Polio Mumps Measles Rheumatic Fever Tuberculosis Exposure to blood/bodily fluids Blood Transfusions Sexual Problems Women Only Last Menstrual Period (Date: ) Was the flow Regular, Irregular, Pain/Cramps Are you currently Pregnant: Yes No Number of Pregnancies: Number of Abortions: Number of Miscarriages: Number of Live Births: Are you currently on Birth Control Method: Date of last mammogram: History of Communicable Diseases? (I.e. HIV, Hep B, etc. Please specify: MEDICAL HISTORY CONTINUED Condition Glaucoma Thyroid Problems Hay Fever Asthma Anaemia Bleeds Easily Osteoporosis Stroke Diabetes Heart Disease Depression High/Low Blood Pressure Family Medical History (please specify relationship) High Cholesterol Alcoholism Genetic Disease Migraine Epilepsy Psoriasis Arthritis Mental Illness Eczema Cancer (Type) Atherosclerosis Other: Condition Habits and Health Access (please specify relationship) Do you Smoke Cigarettes? /day # Years Last Routine Physical (Date): Alcohol: Drinks/week: Last Blood Test (Date): Street Drugs: Last Urine Test (Date): Caffeine Drinks: Last Eye Exam (Date): Sleep Pattern: satisfactory occasionally disturbed Last Dental Exam (Date): Mostly disturbed Last Pap (Women) (Date): Last Prostate/Rectal(Date): Last Electrocardiogram (Date): Hospitalizations and Surgeries (Please indicate the year and reason not including normal pregnancies) Hospitalizations Surgeries Year Illness / Injury Year Illness / Injury

Date of Injury: Was this a workplace injury? YES NO WISB Claim? YES NO Claim# Please describe your injury/illness: Please describe how it happened: Has the injury got Better or Worse since it occurred On a Scale of 0-10, with 10 being the worst pain you have ever experienced, what would the pain on average be? Currently be? Would you describe the pain as: constant dull sharp throbbing tight burning tingling INJURY INFORRMATION Is there anything that makes it feel better? Is there anything that makes it feel worse? Have you received care from anyone yet for this injury? Has it helped? On the diagram, please mark with an X where the injury is, and where you are feeling the most pain. You may also mark on this diagram any pain that is radiating around by using the following: S = Sharp/Stabbing Pain B = Burning Pain N = Numbness P = Pins and Needles Check the words that best describe the pain Tingling Cramping Exausting Radiating Boring Continuous Sheeting Heavy Penetrating Stabbing Tender Nagging Burning Splitting Exerueiating Deep Piercing Unbearable Numb Aching Throbbing Laneinating Cutting Gnawing Teraing Sharp Are you doing anything to help with the pain? Warm Compress Cold Compress Relaxation Techniques Distraction Biofeedback Hypnosis

MEDICATION HISTORY Are you currently taking any pain medications? If so, how long does it take for the pain to return? List (name, dose and frequency) 1 hour 2 hours 3 hours 4 hours 5-12 hours More than 12 hours Do not take any pain medications I prefer to take pain medications: I take my pain medications (in a 24 hour period) On a regular basis Not every day Only when necessary 1-2 times a day I do not take pain medications 3-4 times a day 5-6 times a day 6+ times a day Do you feel you need a stronger type of pain Do you feel that you need to take more of the pain medication? medication then your provider prescribed? YES NO Why? Are you concerned that you use too much pain medication? YES NO Not Sure Why? Do you feel you need more information about your pain medication? YES NO Not Sure Is there something specific you are concerned about? YES NO Not Sure Why? Are you having any side effects caused by your pain medication YES NO Not Sure Explain: Is there anything you are taking/doing for pain that your provider has not provided you? PAIN INVENTORY 1. When does the pain usually begin? 2. How long does it usually last? 3. How often does it occur? Is there any side effects (depression, headaches, etc)? 4. Have you tried Chiropractic? Was it helpful? 5. Have you tried Physiotherapy? Was it helpful? 6. Have you had any x-rays, MRIs,etc yet? Is there anything else we should know about your injury/pain?

BRIEF PAIN INVENTORY

In this document I, my, me and you refer to the patient Health Care Provider refers to any clinician employed or student employed or under the fellowship of our clinicians with Algoma Sports Medicine and Physical Injuries Clinic Medical History and Consent to Assessment I certify that the information contained in this patient intake form is accurate, complete and true. I hereby request and consent to the performance of the required physical examinations and tests be completed in order to diagnose my condition. I understand that the health care provider will attempt to explain the procedures, and will attempt to provide appropriate privacy measures throughout the evaluation of my injury or illness. Treatment Consent CONSENT FORM Algoma Sports Medicines health care providers are trained to assess and treat many different conditions related to sports injuries. Our health care providers are trained in various manual and sports medicine techniques through various organizations in North America, and Europe as part of their medical training. This necessitates hands on techniques when diagnosing and treating various areas of the body. The treatment hypothesis and supportive research entails utilizing whole body muscle balance approach. The health care provider providing care for you will attempt to explain to you each time what they are doing, and you should advise the practitioner if there is any component of the examination or treatment that you are not comfortable with (i.e. feeling a muscle, ribs, body positioning, etc.). The use of manual therapy is a very safe and effective treatment for many sports injuries. There is a probable 1 to 3 in a million chance of catastrophic vascular problems (stroke) with cervical manipulation. The health care provider will inform you that they would like to perform cervical manipulation, and if you wish not to have this technique performed, please advise the health care provider. Manual therapy also carries a small probability of causing a compression fracture in the spine in predisposed individuals with spinal cancers, severe osteoporosis, bony problems, bleeding disorders, or severe degenerative diseases. All of the above can utilize very gentle manual therapy. The most common side effects are pain for a couple of days if the treatment is not aggressive, strain/sprain syndromes can also occur in 1% of cases. Privacy Consent This office may share my health information with other agencies/persons in accordance with current legislation and office policy. I also understand that if desired, someone can be in the room with me while being assessed and treated. Please note that the door may be open at all times during the history, physical or treatment. By signing below I understand that my consent may be withdrawn at any time, except for actions already taken, I release the health care provider providing any assessment or treatment, the facility, directors, officers, and successors from any liabilities, claims, and causes of action, known or unknown, contingent or fixed, that may result from the treatment and/or assessment. I agree not to file a lawsuit or other action to assert a claim. Signature: Date: Witness: Date:

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