QUESTIONNAIRE: PAIN MANAGEMENT This is a general questionnaire designed to obtain the maximum information possible about your condition. Many questions may not seem relevant to your particular history, or you may not know the answer, however, please answer to the best of your ability. If you find a question too personal, please put a line through it. Patient Name: Street Address: City: State: Zip: Cell Phone: Home Phone: Sex: Age: Date of Birth: Work Phone: Who is your general or primary doctor? What is their address? How often do you see a doctor? 3 times a month or more 1 or 2 times a month More than 3 times a year Yearly Rarely What other doctors have you seen for treatment of the pain? Doctor Address Phone # Last Seen Do we need to send our reports to your attorney? Yes No If yes, attorney name, address, phone number: Are you right-handed or left handed? RIGHT LEFT AMBIDEXTROUS Date of Injury: Please describe your problem in your own words, including dates when possible (use extra sheet if necessary): When did your pain start? What caused the pain? Page 1 of 7
QUESTIONNAIRE: PAIN MANAGEMENT Patient Name: Mark the areas of your body where you feel the described sensations. Use the appropriate symbols. Include all affected areas: o o o o ------..... XXXX ///// Numbness Pins & Needles Aching Cramping Burning Stabbing Circle the number that corresponds to the severity of your pain. On the scale from 0 to 10, 0 means no pain and 10 is the most severe pain you can imagine: 0 1 2 3 4 5 6 7 8 9 10 Does your pain vary in intensity? Yes No The WORST pain you ever have (from 0-10) is: The LEAST pain you ever have (from 0-10) is: What makes your pain worse? Check items that decrease your pain: Rest / Bed Walking / Standing Medications Drugs Alcohol THC Lying Down Being Around People Physical Activity Other: Page 2 of 7
QUESTIONNAIRE: PAIN MANAGEMENT Patient Name: List any physical activities you used to do frequently that you don t do any more because of pain: How many hours per day (average) must you lie down or rest because of pain? How many times per day (average) must you lie down because of pain? How many times per day (average) must you stop what you are doing because of pain? Tests: List the tests you have had for this condition: X-Rays CT Scan MRI EMG / NCV Other: What have you been told is your diagnosis? Location (body part) Approximate date / year Facility done? Do you think the pain is due to something more serious or different than doctors have told you? Yes No Not sure Have you ever had injections for your pain problem? Yes No How many? What type: Where: Physician: Did it help? Yes No What was the longest duration of pain relief following an injection? Please select the response that most accurately depicts your experience with the following treatments: Have not had treatment Lasting benefit Temporary benefit No help Made worse Nerve Stimulator (TENS) Physical Therapy Acupuncture Heating pads Ultrasound Massage Manipulations/Chiropractic Pain management unit Other treatments (not counting medicines) Please list type of treatment: Page 3 of 7
Patient Name: QUESTIONNAIRE: PAIN MANAGEMENT Who do you work for currently? Is this the same employer as at the time of injury? Yes No Occupation: How long in this position? Brief description of usual job duties: Work status: Working full-time Working part-time Student Disabled Unemployed Retired If disabled, (as worker / student / homemaker), date last worked: If disabled, have you tried to return to work? Full-time Part-time No Have you received disability income related to this condition? Yes, receive it now Yes, in the past No, never received it Have you had any prior on-the-job injuries? Yes No If yes, please describe the injury, list the date, and list the duration of time you were off work, if any: Injury Date Time Loss Was there an impairment or legal settlement related to this injury? Yes No Have you had any automobile accident injuries? Yes No If yes, please describe all injuries and dates they occurred: Do you have trouble falling asleep? Never Sometimes Usually Always Does pain frequently awaken you? Yes No If yes, how many times per night? When awakened, do you: Empty Bladder Take Medicine Sit Up a While Other, describe: Do you easily return to sleep? Yes No Sleep Position: Back Stomach Right Side Left Side Page 4 of 7
Patient Name: QUESTIONNAIRE: PAIN MANAGEMENT Has pain interfered with your desire for a social life? No interference Minimal change Considerable change Stops desire for social life Has pain interfered with your ability for a social life? No interference Minimal change Considerable change Completely prevents Has pain interfered with your desire for hobbies/recreation? No interference Minimal change Considerable change Stops desire for recreation Has pain interfered with your ability for hobbies/recreation? No interference Minimal change Considerable change Prevents recreation Please list recreational activities / sports you enjoy: Sports / Recreational Activity Times per week Hours per week Are there current or recent stressful situations in your life? Yes No Not sure Does stress increase your pain? Yes No Have no stress What do you hope will be the result of this evaluation? Medical diagnosis (discover the cause of the pain) Recommendation for surgery Recommendation for rehabilitation Determine the existence of a disability Recommendation for medicines Other, describe: If you are treated here, what are the results you hope for: Pain reduction Increased recreation Improved emotional well-being Return to work Elimination of drugs Increased socialization Other: If you are treated here, what are the results you expect? Do you ever feel your condition is hopeless? Never Sometimes Most of the time All the time Page 5 of 7
QUESTIONNAIRE: PAIN MANAGEMENT Medications: List all medicines that you have been taking recently. Include vitamins and nonprescription medicines as well as prescribed medicine. Indicate the amount you usually take in a day or week (look on bottle): Name of Medication Dosage (# of mg) # of Tablet/Capsule (1 or 2) How often per day? List medicines you have tried in the past for the pain (include why/when used, why stopped): Medication Was it effective? Side effects When was it used? How long did you take it? Why was it stopped? GENERAL MEDICAL HISTORY Check any conditions you have ever had: Anxiety Hepatitis (type) Psychiatric Illness (type) Arthritis Herpes Asthma Hypertension / High Blood Pressure Lung Disease Cancer (type) Kidney Disease Ulcer Depression Liver Disease Rheumatic Fever Diabetes (type) Phlebitis Stroke Gonorrhea Pneumonia Syphilis Heart Murmur Polio Thyroid Trouble: Heart Attack Other: Allergies and Reactions to Medicines or other Substances: No known drug allergies Medication Reaction Medication Reaction Page 6 of 7
QUESTIONNAIRE: PAIN MANAGEMENT Patient Name: Previous Hospitalizations / Serious Illness / Injuries / Surgeries: Year Diagnosis Description Is there a history of any of the following in a blood relative? (Check box if YES) Alcoholism Chronic Pain Stroke Psychiatric Illness, type: High Blood Pressure Disability Depression Drug Addiction, type: Migraine Diabetes Heart Attack Cancer, type: Other: Father: Alive, age: Deceased, age:, cause: Mother: Alive, age: Deceased, age:, cause: # of Brothers: Alive, age: Deceased, age:, cause: # of Sisters: Alive, age: Deceased, age:, cause: Number of Children: Boys, Ages Girls, Ages Alcohol (amount per day or week): Have you had a problem with alcohol? Yes No Caffeine (cups per day): Recreational Drugs: Marijuana Yes No How often: Last Used: Circle years of School completed: 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Marital Status (check one or more): Single Married Widowed Divorced Separated Remarried Living Together Living Arrangements: Apartment House Other: Tobacco (type, amount per day / week): Previous Smoker? Yes No If yes, how many years smoked: Quit date: Do you feel safe at home? Yes No For whom do you give us permission to talk to regarding your healthcare services? I have carefully reviewed this questionnaire and completed it to the best of my knowledge. Patient, Parent, or Legal Guardian (circle one) Witness Page 7 of 7
QUESTIONNAIRE: Functional History Patient Name: Date of Birth: Today s In a typical day, how many hours can you sit? In a typical day, how many hours can you stand? In a typical day, how many hours can you walk? At any one time, how many hours can you sit? At any one time, how many hours can you stand? At any one time, how many hours can you walk? How many pounds can you lift? Never Occasionally Frequently Continuously Up to 5 pounds 6-10 pounds 11-20 pounds 21-25 pounds 26-50 pounds 51-100 pounds How many pounds can you carry? Never Occasionally Frequently Continuously Up to 5 pounds 6-10 pounds 11-20 pounds 21-25 pounds 26-50 pounds 51-100 pounds Revised 09/15/2016 Page 1 of 2
QUESTIONNAIRE: Functional History Patient Name: Date of Birth: Today s How far can you walk? 0-2 blocks 4-6 blocks A mile or more Can you use your right hand for: Simple grasping Yes No Pushing and pulling arm control Yes No Fine manipulation Yes No Can you use your left hand for: Simple grasping Yes No Pushing and pulling arm control Yes No Fine manipulation Yes No Can you use your right foot for repetitive movements in pushing and pulling controls: Yes No Can you use your left foot for repetitive movements in pushing and pulling controls: Yes No Are you able to: Never Occasionally Frequently Continuously Bend Squat Crawl Climb Reach Get on knees Are you able to dress, eat, care for your hair, wash, and toilet independently? Yes No I have carefully reviewed this questionnaire and completed it to the best of my knowledge. Patient, Parent, or Legal Guardian (circle one) Witness Revised 09/15/2016 Page 2 of 2
QUESTIONNAIRE: Pain Disability Patient Name: DOB: Today s Instructions: These questions are your views about how your pain now affects how you function in everyday activities. Please answer every question and mark only ONE number on each scale that best describes how you feel. 1. Does your pain interfere with your normal work inside and outside the home? Work normally Unable to work at all 2. Does your pain interfere with personal care such as washing, dressing, etc? Take care of myself completely Need help with all my personal care 3. Does your pain interfere with your traveling? Travel anywhere I like Only travel to see doctors 4. Does your pain affect your ability to sit or stand? No problems Cannot sit/stand at all 5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things? No problems Cannot do at all 6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat? No problems Cannot do at all 7. Does your pain affect your ability to walk or run? No problems Cannot walk/run at all 8. Has your income declined since your pain began? No decline Lost all income 9. Do you have to take pain medication every day to control your pain? No medication needed On pain medication throughout the day 10. Does your pain force you to see doctors much more often than before your pain began? Never see doctors See doctors weekly 11. Does your pain interfere with your ability to see the people who are important to you as much as you would like? No problem Never see them 12. Does your pain interfere with recreational activities and hobbies that are important to you? No interference Total interference 13. Do you need help from family & friends to complete everyday tasks (both outside the home and housework) because of your pain? Never need help Need help all the time 14. Do you now feel more depressed, tense, or anxious than before your pain began? No depression/tension Severe depression/tension 15. Are there emotional problems caused by your pain that interfere with your family, social, and/or work activities? No problems Severe problems I have carefully reviewed this questionnaire and completed it to the best of my knowledge. Patient, Parent, or Legal Guardian (circle one) Witness Page 1 of 1 Revised 09/16/2016
QUESTIONNAIRE: Review of Symptoms (ROS) Dr Kahn Patient Name: Date of Birth: Today s Constitutional Recent weight gain Recent weight loss Fever or soaking sweats at night Fatigue Weakness Numbness Headaches 1-2 times+/week Difficulty walking Loss of consciousness Eyes Vision problems not corrected by glasses Glaucoma Eye lens implant Eye prosthesis Contact lenses Ears, Nose, Throat Chronic stuffy nose Nasal polyps Frequent nosebleeds Sinus problems Hay fever allergies Difficulty swallowing Dentures or partial plates Capped teeth Loose teeth Orthodontic braces Cardiovascular Heart murmur Prolapsed mitral valve Heart pacemaker Irregular heartbeat Palpitations Fainting spells Chest pain on exertion Chest pain at night Heart attack Congestive heart failure Swelling in feet or ankles Shortness of breath lying flat Shortness of breath at night Blood clots Pulmonary embolism High blood pressure Low blood pressure Respiratory Asthma or wheezing Bronchitis Emphysema Pneumonia Chronic cough Change in amount of phlegm Change in color of phlegm Coughing up blood Collapsed lung Tuberculosis exposure Blueness of your fingernails Gastrointestinal Ulcers Hiatal Hernia Frequent heartburn Ulcerative Colitis Diverticulitis Colostomy or other ostomy Hepatitis or yellow jaundice Liver Cirrhosis Gallbladder problems Vomiting blood Black, tarry bowel movements Blood in bowel movements Change in bowel habits Genitourinary Kidney stones Kidney infections Kidney failure Dialysis Prostate problems Bladder infections Blood in urine Difficulty urinating Lose urine at times Musculoskeletal Fractures or broken bones Arthritis Difficulty opening mouth wide Scoliosis Spinal column deformity Dermatologic Skin rash or sores Itching Color change, pigmentation, nodules Pressure ulcers Neurologic Seizure Epilepsy Stroke Brain aneurysm or hemorrhage Multiple Sclerosis Nerve injury or numbness Psychiatric Depression Anxiety Mental disorder Endocrine Diabetes Insulin use Low blood sugar (hypoglycemia) Thyroid problems Steroid use Allergic / Immunologic Herpes exposure AIDS exposure Seasonal allergies Hematologic Abnormal bleeding problems Anemia or low blood counts Blood transfusion Hemophilia Sickle cell anemia Lymphatic Swollen glands Masses in neck, armpit, or groin Lymphedema Others Sexual problems Muscular Dystrophy Myasthenia Gravis Malignant hyperthermia Bad reaction to local anesthetic Tumor Down syndrome Cancer Chemotherapy Radiation therapy Recent acute illness Recent hospitalization Recent surgical operation I have carefully reviewed this questionnaire and completed it to the best of my knowledge. Patient, Parent, or Legal Guardian (circle one)