PRIMARY COMPLAINT When did your pain start?

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1 NEW PATIENT HISTORY FORM (This frm must be cmpleted prir t being seen) Name: DOB: Date: Referring Physician Primary Physician PRIMARY COMPLAINT When did yur pain start? Under what circumstances did yur pain begin? (Please select the apprpriate indicatr listed belw) At wrk, but NOT an accident Accident at wrk Fllwing surgery Mtr vehicle accident Fllwing illness Accident at hme Pain began with n knwn cause Other Where is the lcatin f yur pain? Please shade the painful areas n the diagram belw xxxx fr mst severe pain fr less severe pain *** fr tingling/burning NUMERIC PAIN SCALE Please circle the number that best describes the amunt f pain yu feel right nw. wrst N pain 0 1 2 3 4 5 6 7 8 9 10 pain Imaginable What is the highest number that yur pain ges t? What is the lwest number that yur pain ges t?

2 What best describes yur pain? (Please circle all that apply) Burning stabbing shting aching dull electrical deep vague sharp cnstant intermittent daily Other? D yu have any numbness? Yes N If yes, where? D yu have any weakness? Yes N If yes, where? What makes yur pain wrse? (please circle all that apply) exercise bending frward bending backwards walking cld stress climbing stairs lifting sitting standing heat wrk driving cugh/sneeze sexual activity light tuch ther: (Please describe): What relieves yur pain? (please circle all that apply) lying dwn sitting standing walking physical therapy exercise ice heat medicatins bath/shwer meditatin relaxatin Other (describe): Have yu ever been treated at anther pain management center r prgram? Yes N If yes, where? When? MEDICATIONS D yu take any bld thinning medicatin? What? (This is nt an all-inclusive list but examples f sme anticagulants include Cumadin, Plavix, Aggranx, r thers) List all ther pain medicatins that yu have tried in the past and why yu stpped: List all medicatins that yu are taking nw. (Include ver the cunter, herbal, vitamins, and ther supplemental medicatins)

3 Medicatin Dse (mg) Hw ften? (# times/day) What is this medicatin fr? Date started Prescribing Dctr ALLERGIES Please list any knwn drug, fd, r envirnmental allergies and indicate the adverse effect/reactin: MEDICAL HISTORY (please check all that apply) Cardivascular Respiratry Gastrintestinal Endcrine Hematlgic Chest Pain Asthma Acid Reflux/GERD Heart Attack Emphysema Ulcers Heart Disease Chrnic Brnchitis Plyps Heart Rhythm Disturbances Easy bruising Diabetes Anticagulatin Arterial Insufficiency Insulin Venus Insufficiency Bwel prblems High Bld Pressure Lw Bld Pressure Bld thinners Clitis Hiatal Hernia Emblism Irritable Bwel Syndrme Liver Disease Obesity Bleeding disrders Hypthyrid Anemia Hyperthyrid Frequent Pneumnia Hepatitis A, B, C Psitive TB Test Pancreatitis Frequent Clds/Sre Thrat Bld clts Abnrmal Chest x-ray Gallbladder prblems Crhn s Disease Special Diet Other Neurlgical Psychlgical Geniturinary Musculskeletal

4 Memry prblems Seizures Strke Mvement Disrder Muscular Dystrphy Neurpathy Migraine Epilepsy Headaches Nervus Breakdwn Depressin Anxiety Panic Disrder Psychsis Alchl r drug abuse Other Sexual Dysfunctin Sexually Transmitted Disease Prstate Disease Kidney Prblems Chrnic Infectin Bladder Prblems Fibrmyalgia Rheumatid Arthritis Ostearthritis Osteprsis Back Prblems Neck Prblems Cancer Miscellaneus General Allergic/Immunlgical Site Glaucma Medical Equipment Autimmune disrder Diagnsis Date Cataracts Cane Lupus, Sjgren s Walker Raynaud s Syndrme Wheel Chair Chemtherapy Visual Prblems Immune deficiency Hspital Bed Radiatin Hearing Lss HIV Oxygen at LPM Other Chrnic Skin Disrder Pregnancy Date f last perid SURGICAL HISTORY (Please list all surgeries) DATE SURGERY DOCTOR FAMILY MEDICAL HISTORY Please check what applies Back Prblems Migraines Heart Attack Cancer Diabetes Seizures Depressin Strke Anxiety Hypertensin Has family experienced any prblems resulting in similar cnditins r chrnic pain? Yes N SOCIAL HISTORY Smking habits: packs per day fr years Alchl intake: Amunt & Frequency

5 PSYCHOSOCIAL HISTORY Highest level f educatin Are yu able t care fr yurself Are yu ging t schl nw? if nt, wh helps yu? Have yu fallen lately? Y N When? D yu use any assistive device at hme? (walker, cane, etc.) What exercise r recreatinal activities d yu enjy? Hw ften d yu exercise r d the abve activities? D yu feel safe in yur hme? Yes N If nt, why? Have there been any ther stressful life experiences recently? Yes N If s, explain: Have yu ever had thughts f suicide r harming yurself? Yes N N If yes, did yu seek help? Yes Have yu ever had thughts f harming smene else? Yes N If yes, wh? Have yu been under the care f a mental health prfessinal? Yes N If yes, wh? Have yu received treatment fr alchl r substance (legal/illegal) abuse? Yes N If yes, when? MEDICAL TESTING (Select the medical tests belw that have been dne t evaluate yur pain) Date (apprximate) Result (if knwn) X-ray CT Scan Myelgram MRI Discgram Bne Scan EMG

6 MISCELLANEOUS Are yu, r have yu ever been, invlved with any f the fllwing? Disability: Litigatin/lawsuit(s): Nt receiving r seeking disability N & nt intending pain-related litigatin/lawsuit Nt receiving but seeking r planning t seek disability Currently in pain related litigatin/lawsuit Receiving disability Past litigatin/lawsuit r legal invlvements related t pain cnditin Mtr Vehicle Accidents: Pain nt related t mtr vehicle accident Pain related t mtr vehicle accident and settlement pending Pain related t mtr vehicle accident but n settlement pending r necessary D yu have any ther litigatin r lawsuits nging, pending, planned, r under cnsideratin? Yes N (If s, please explain) REVIEW OF SYSTEMS (Please circle any f the listed symptms that are current prblems fr yu) Cnstitutinal: fever chills weight lss r gain fatigue Eyes: duble visin blurry visin need fr glasses injury r surgery Ear, Nse, Thrat: sinusitis hearing lss ringing in ears sres vice change swelling Cardivascular: palpitatins leg swelling heart attack chest pain high bld pressure Respiratry: shrtness f breath asthma cugh spitting up bld wheezing Gastrintestinal: lss f appetite nausea vmiting bld in stls Geniturinary: frequent r painful urinatin incntinence infectins irregular menses Musculskeletal: Jint pain r stiffness weakness injury r surgery swelling spasm Skin/Breast: rashes ulcers nail changes breast pain r lump r discharge Neurlgical: strke r TIA headaches dizziness seizures lss f balance Psychlgical: memry lss depressin insmnia anxiety nervusness Endcrine: diabetes thyrid prblems excessive thirst r urinatin Hematlgic: bleeding r bruising tendency phlebitis DVT bld clts transfusin PAIN MANAGEMENT GOALS & EXPECTATIONS What d yu expect frm ur pain prgram? (select the ONE best answer) A diagnsis (t help find the cause f pain) Help in cping with the pain A reductin in pain A cure N expectatins D nt knw what t expect

7 PAST TREATMENTS (Please select the treatments yu have received fr yur pain prblem, and what was the result?) Indicate Pain Therapies Tried Nt Tried Imprved N change Wrse Cmments Drug Detxificatin Epidural sterid injectins Facet jint injectins Trigger pint injectins Nerve (lumbar sympathetic, stellate ganglin, etc.) blcks Spinal crd stimulatin Medicatin pump Radiatin therapy Physical therapy Exercise Manipulatins/Mbilizatins Tractin Exercise/Aerbic cnditining Passive (heat, ice, gentle massage, ultrasund) Aqua/water/pl therapy Trigger pint therapy/deep tissue massage/acupressure Occupatinal therapy Acupuncture Chirpractic Prsthetics/Orthtics (e.g. braces, supprts, etc) Electric stimulatin (TENS) Bifeedback/relaxatin Yga Hypnsis Other

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