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Name Date of birth Age Please fill out BOTH SIDES of this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your pain? Color the areas on this diagram where your pain has been for the last 2-3 weeks: RED = Excruciating pain GREEN = Moderate pain BLUE = Severe pain YELLOW = Mild pain WHEN did your pain start? Medical Pain History 1 THIS COLUMN FOR OFFICE STAFF USE ONLY. CC & HPI timing 1/4 duration 2/4 location 3/4 quality 4/4 context 5/4 modifying factors 6/4 severity 7/4 sleep In the last 2-3 weeks, WHEN does your pain occur? intermittent (on/off) 8-16 hrs/day less than 8 hrs/day constant HOW did your pain start? auto accident work related after surgery fall (not at work) other, describe: WHAT does your pain feel like? (check all that apply) burning mild sharp moderate dull severe stabbing aching cramping other, describe: What has been used to TREAT your pain? (check all that apply) medications individual psychotherapy other Pain Center biofeedback group psychotherapy physical therapy injections relaxation training occupational therapy treatments in emergency room (ER) - how many times have you been to the ER for pain control over the last 3 months? other, describe: reviewed by What DECREASES your pain? (check all that apply) sitting bending heat relaxation exercises medications standing lying flat cold rest injections walking not working physical therapy other, describe: Copyright 2010 Mermaid Medical ALL RIGHTS RESERVED. v0329 Medical Pain History 1

Please fill out this form as completely as possible. Med Pain Hx 2 What INCREASES your pain? (check all that apply) sitting going up or down stairs driving a vehicle standing bending or transferring positions sports, physical recreation, crafts, or hobbies walking employment or working self-care (bathing, dressing, toileting, etc.) lifting, carrying, housework, or yard work (laundry, meal preparation, etc.) other, describe: THIS COLUMN FOR OFFICE STAFF USE ONLY. HPI (cont'd) CARF Does your pain keep you from falling asleep at night? Does your pain awaken you at night? What is your goal for treatment at the Pain Center? (For example: What are the activities you would like to do if the pain was better controlled?) Do you have any other comments about your pain, not already noted here? Past Medical History - What are your past or current medical problems? (check all that apply) heart disease rheumatic fever high blood pressure lung disease bronchitis or pneumonia asthma liver or gall bladder problem hepatitis peptic ulcer disease colitis pancreatitis bladder or kidney disease arthritis diabetes thyroid or other endocrine disorder anemia or blood disease bleeding disorder tumor or cancer neurological disease seizures stroke tension headache migraine headache drug addiction or alcoholism chemical dependency treatment mental or nervous disorder other medical or pain problems not previously noted, describe: PMH 1/3 Past Surgical History - List ALL surgery & s (month/year): PSH 1/3 meds 2/3 allergies 2/3 reviewed by Do you use anticoagulants (such as heparin, coumadin, Fragmin, Lovenox, enoxaparin, Normiflo, ardeparin, Orgaran, danaparoid)? (If yes, please include all anticoagulants on your medication list on the next page.) Do you use over-the-counter medications? (If yes, please include all over-the-counter medications on your medication list on the next page.) Do you use recreational drugs or medications which were prescribed for someone else? (If yes, please include all these medications on your medication list on the next page.) Copyright 2010 Mermaid Medical ALL RIGHTS RESERVED. v0329 Name DOB Medical Pain History 2

This list will be verified & upd every time you visit the Pain Center. Please write legibly. Medication Reconciliation 1 Med Pain Hx 3 Name Date of Birth MEDICATIONS - Please list all your current prescribed and over-the-counter medications: START YOUR COLUMN continue your list COLUMN continue your list COLUMN 1 LIST HERE 2 here from column 1 3 here from column 2 medication - dose - frequency medication - dose - frequency medication - dose - frequency Copyright 2010 Mermaid Medical ALL RIGHTS RESERVED. v0329 Medication Reconciliation 1 - Med Pain Hx 3

Please fill out the top part (ALLERGIES) of this page. Medication Reconciliation 2 - Med Pain Hx 4 Allergies or medication problems: Please list all the medications you are allergic to and/or have had problems tolerating. Briefly list the specific allergy or problem which occurred. medication - allergy or problem medication - allergy or problem THIS SECTION FOR PAIN CENTER STAFF COMPLETION ONLY: Copyright 2010 Mermaid Medical ALL RIGHTS RESERVED. v0329 Name DOB Medication Reconciliation 2 Med Pain Hx 4

Please fill out BOTH SIDES of this form as completely as possible. This information will determine how we treat your pain problem. Medical Pain History 5 Review of systems - Do you have? Please check yes or no for each item: THIS constitutional 1/10 gastrointestinal 6/10 skin 10/10 COLUMN weight loss FOR OFFICE heartburn skin itching STAFF USE fatigue peptic ulcers skin rash ONLY. chills/fever nausea skin infection ROS 10/14 decreased appetite vomiting endocrine 11/10 eyes 2/10 diarrhea hot flashes eye discharge constipation hair loss glasses or contacts laxative use always hot excess tearing jaundice always cold eye pain loss of bowel control always thirsty vision changes genitourinary 7/10 hematologic - lymphatic 12/10 ENT 3/10 frequent urination easy bruising earache urinary tract infections easy bleeding ear discharge anemia hearing loss painful urination swollen nodes ringing of the ears urinary retention allergic - immunologic 13/10 ear infection urinary dribbling AIDS post-nasal drip loss of urinary control steroid use sore throat frequent infections musculoskeletal 8/10 bleeding gums allergies joint pain cardiovascular 4/10 hives joint swelling chest pain psychiatric 14/10 joint stiffness angina anxiety muscle pain palpitations depression muscle swelling heart murmur mood swings neurological 9/10 short of breath with nightmares activity or at rest numbness FOR MEN ONLY tingling respiratory 5/10 tremor Do you have problems with chronic cough erections? fainting wheezing FOR WOMEN ONLY headaches short of breath at rest weakness Could you be pregnant now? dizziness If you smoke, how much do Is your father alive? Marital status: Are you? PFSH 3/3 you smoke? What health problems does your single married If you drink beverages with father have? (If deceased, cause divorced widowed alcohol, how much do you of death?) Do you have children or other consume? dependents at home? If yes, please reviewed by Has anyone complained about list children s ages, or your drinking? Is your mother alive? describe other dependents: If yes, who complained? What health problems does your mother have? (If deceased, If you drink beverages with cause of death?) caffeine, how much do you consume? Copyright 2010 Mermaid Medical ALL RIGHTS RESERVED. v0329 Name DOB Medical Pain History 5

Current employer: How many years have you worked for this employer? Are you working? If not working, when did you last work? If not working, when will your off work slip expire? If not working, who took you off work? Are you on disability? If yes, when did your disability start? If yes, which type of disability do you have? (check all that apply) Please fill out this form as completely as possible. Med Pain Hx 6 Occupation (brief job description or type of work activity): short term disability long term disability social security disability If not working, is pain preventing you from working? If not working, would you like to return to work? If yes, what was the medical diagnosis for your disability? other, describe: THIS COLUMN FOR OFFICE STAFF USE ONLY. work 3/3 WC disability litigation Are you on Workers Compensation (WC)? If yes, when did your Is your WC claim in dispute? WC start? If you are involved in a lawsuit(s), who is the lawsuit against? (check all that apply) lawsuit regarding a disability claim other, describe: lawsuit regarding an auto accident lawsuit with Workers Compensation Diagnostics - What diagnostic studies, such as xrays, CT scans, MRI s, myelograms, EMG's (electromyogram), or bone scans have been done within the last 5 years? List below, including type of study, completed, which part of the body was studied, and the hospital or office where the study was performed. For example: MRI - 2001 - low back - Sparrow diagnostic test - - part of body - where diagnostic test - - part of body - where diagnostics Physicians, psychologists, or healthcare professionals involved in your care - List all physicians and mental health professionals you have consulted (including those for non-pain complaints): name - last seen - office phone # name - last seen - office phone # physicians psychologists other providers reviewed by Copyright 2010 Mermaid Medical ALL RIGHTS RESERVED. v0329 Name DOB Medical Pain History 6

Please fill out BOTH SIDES of this form as completely as possible. This information will determine how we treat your pain problem. Psychological Pain History 1 Name Date of birth Today s How has pain affected your personality? (check all that apply NOW) THIS COLUMN FOR OFFICE STAFF USE ONLY. mildly upset moderately upset severely upset no effect disagreeable incapacitated panicked other, describe: moody irritable mildly depressed moderately depressed severely depressed uncooperative complaining suicidal discouraged unhappy desperate mildly withdrawn moderately withdrawn severely withdrawn tired dull bitter anxious frustrated PSYCH Since the pain, what are you concerned about? loss of recreational activities change in family interaction change in sexual desire, ability to continue or go interest or ability back to work the pain lasting forever lack of interest in getting concentration difficulties together with people other, describe: (check all that apply NOW) unidentified medical problems poor sleep memory difficulties daytime fatigue What stress has the pain caused you at home? What stress has the pain caused you at work? What stresses were you under before the pain? Are you depressed now? yes no Have you ever been depressed before in your life? yes no Have you ever attempted suicide? yes no Describe your mood when you have severe pain: reviewed by Describe how you cope with the pain: Explain in your own words why you have the pain: Copyright 2010 Mermaid Medical ALL RIGHTS RESERVED. v0329 Psychological Pain History 1

Please fill out this form as completely as possible. Psych Pain Hx 2 Do you currently use alcohol for controlling pain? THIS COLUMN FOR OFFICE Have you ever If yes, please describe: STAFF USE been in treatment for ONLY. abuse of alcohol, PSYCH cocaine, crack, marijuana, or other drugs? Have you ever been in legal trouble because of alcohol, cocaine, crack, marijuana, or other drugs? Describe yourself. What kind of person are you? If yes, please describe: What is most important in your life? Do you want to see a pain psychologist to help you deal with the pain? Have you ever seen a counselor, psychologist, or psychiatrist at any time in your life? If yes, please list all mental health professionals (psychiatrists, psychologists, social workers) you have seen: name - last seen - office phone # name - last seen - office phone # psychologists, other mental health professionals In addition to decreased pain, what do you hope to get from treatment at the Pain Center? reviewed by Copyright 2010 Mermaid Medical ALL RIGHTS RESERVED. v0329 Name DOB Psychological Pain History 2

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