Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)

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Transcription:

Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving sharp shooting electric-like stabbing dull achy deep radiates (travels) to: arms legs Other: Severity: minor moderate severe Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain) What makes your pain worse?: standing sitting bending forward bending backward side bending twisting sneezing coughing walking stress touching of the skin cold weather During exercise after exercise What makes your pain less (better)? standing sitting bending forward bending backward walking stress cold (ice) exercise injections pain medication alcohol Physical therapy What treatments have you tried? Medications Physical Therapy Acupuncture injections psychology/counseling TENS Unit Chiropractor Pain Management Services Elsewhere Please specify your response

What diagnostic tests have you undergone? A) Imaging MRI CT X-ray B) EMG/NCV C) Interventional procedures Past Medical History: PLEASE LIST ALL ALLERGIES including medications, foods and any others: Medication(s) Dose Frequency (how often do you take) Duration Are you on a blood thinner? YES NO If yes please specify? In the past have you had any of the following medical problems? (Please check all that apply to you.) Cardiovascular Arrhythmia (irregular heartbeat) Coronary artery disease Congestive heart failure Hyperlipidemia (high cholesterol) Hypertension (high blood pressure) Myocardial infarction (heart attack) Poor circulation Other Pulmonary Asthma COPD (chronic obstructive pulmonary disease) Chronic bronchitis Tuberculosis

Gastrointestinal Cholelithiasis (gallstones) Cirrhosis Colon polyps GERD (gastroesophageal reflux disease, indigestion) Peptic ulcer disease Musculoskeletal/Connective Tissue Chronic pain Specify Fibromyalgia Fractures Specify: Osteoarthritis Osteoporosis Rheumatoid arthritis Other Renal/Genitourinary BPH (benign prostatic hypertrophy) Endometriosis Kidney disease or stones Renal failure Urinary incontinence or retention Endocrine Diabetes Type I Type II Hyperthyroidism Hypothyroidism Hematologic Anemia Neurologic Psychiatric Carotid stenosis Anxiety CVA (stroke, TIA) Bipolar disorder Headaches Migraine Tension Depression Multiple sclerosis Obsessive/Compulsive disorder Parkinson's disease Post-traumatic stress disorder Seizure disorder Cancer - Specify location and types of treatment:

Past Surgical History: I have never had surgery. Angioplasty Coronary Artery Stent Appendectomy Fracture Arthroscopy Hernia repair Location Hysterectomy Carotid endarterectomy Right Left Cataract extraction Right Left Cholecystectomy (gall bladder removal) Coronary artery bypass graft Joint replacement Pacemaker Spine surgery Tonsillectomy/Adenoidectomy Social History Smoking Status Do you smoke? Yes No If yes, what is your usage per day: Alcohol Do you drink alcohol: Yes No If yes, how much do you drink per week: Illicit Drugs Do you use any illicit drugs? Yes No If yes, please explain:

Family Medical History: Please check if a family member has had any of the following medical problems: Father Mother Brother Sister Cardiovascular: Endocrine: Gastrointestinal: Genitourinary: Hematologic(blood) Musculoskeletal: Neurological: Psychiatric: Pulmonary: Cancer: Specify Type: Other: Specify Type:

Please indicate the area of your pain: Draw an: X - to indicate areas of deep pain Z- to indicate areas of tingling/numbness Use arrows to show areas that pain/tingling radiates (travels)

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