IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED

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Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your appointment date/time. Our office which is located at 10995 Allisonville Rd., Suite 100,. We ask that you complete this packet and bring it with you to your first visit. If you are scheduled for an initial evaluation you will need to report to the office 30 minutes prior to your appointment time to complete any additional information we may need. Due to limited seating in each waiting area, we ask only the patient and one caregiver be present. If you must bring your children with you, you will need to bring someone to watch them in the waiting area while you are at your appointment. The estimated time you may be here for your first appointment is 2 hours. You may be asked to change into an exam gown for your first visit. This is helpful during your initial evaluation for your pain management. On the day of your appointment you will need to make sure you present your insurance card(s), driver s license, and any current medications. We will collect any co-payments if any is due. We do accept cash, cashier s check, money order, Visa and Mastercard. IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED. We are pleased to have the opportunity to be able to assist you with your pain management needs. If you have any questions, please feel free to contact our office at (317) 842-7928. We ask that you extend us the courtesy of notifying our office 24 hours in advance if you need to change or cancel your appointment. Missed or late appointments without prior notice may be subject to a fee and future appointments may not be scheduled. If you are late, your appointment may be rescheduled to the next available date. Sincerely, The Pain Management Center AHN PAIN FISHERS (05/2012) pg 1 of 9

Initial Patient History Form What are you seeing us for? Who referred you to the Pain Clinic? When did this pain begin? Is it associated with an accident? Yes No If yes, Date Please describe the details surrounding the event If you need additional space to tell us about the accident, please continue writing on an additional sheet of paper. If you can type the details on a word processor, please bring both a printed and a digital copy. Describe your pain Where do you hurt? How bad is your pain? With 0 being no pain and 10 the worst pain you can imagine, please circle: How bad your pain is now? 0 1 2 3 4 5 6 7 8 9 10 The least your pain is in the course of a month 0 1 2 3 4 5 6 7 8 9 10 The worst your pain is in the course of a month 0 1 2 3 4 5 6 7 8 9 10 Please draw on the pain drawing where you hurt. If the pain travels, draw this on the body. What words describe your pain? (circle all that apply) Sharp Dull Achy Shooting Burning Boring What have other doctors diagnosed this problem as? 1. 2. 3. 4. What tests have you undergone for this problem? Please list where the tests were done. X-rays EMG MRI Blood tests Psychological testing AHN PAIN FISHERS (05/2012) pg 2 of 9

What treatments have you undergone for this problem? Medications? Please list. Have you had physical therapy for this problem? TENS or other skin surface electrical treatment? Chiropractic? VAXD? Injections? Surgery? If so, please describe. Surgery Surgeon Date Hospital Do you have other health issues (hypertension, diabetes, thyroid trouble, etc.)? If so, please list them. Other Surgical History? If so, please describe. Surgery Surgeon Date Hospital AHN PAIN FISHERS (05/2012) pg 3 of 9

Please list all the medications you are taking presently. Medicine Strength How Often? Who Prescribed? What medications have you taken in the past but you are no longer taking? Why did you stop taking it? What other treatments have you undergone? What for and did it help? Do you live with anyone now? Please list. Are your parents living? Have your parents had a pain condition? If so, please describe. Does anyone in your family have a chronic pain condition? Please list their relationship and condition. Do you have any relatives with a drug or alcohol problem (parents, children, siblings)?... Yes No Do you smoke tobacco?... Yes No Do you consume alcohol?... Yes No AHN PAIN FISHERS (05/2012) pg 4 of 9

Occupation What is your occupation? Who is your employer? Write your job description. Review of Systems (Check all that apply and fill in the blanks) General Fever Dizziness Chills Forgetfulness Tired Weight Loss - How much? Trouble Sleeping - Hours slept a night Weight Gain - How much? Neurologic Headache What part of your head? How often? How long do they last? What treatments work? What treatments did not work? Pain in legs Pain in arms Respiratory Sleep apnea Voice change Cough Nasal congestion Coughing up sputum Dry Mouth Sore throat Wheezing Short of breath in cold Draining sinuses Short of breath when walking up a flight of stairs Do you smoke tobacco products? If so, how many packs a day? Cardiac Chest pain or tightness Rapid heart beat Short of breath when walking a block Passed out Short of breath when lying down Heart Cath or Heart Surgery Have to sleep with your head up Wake up at night short of breath Vascular Pain in legs when walking Frostbite Fingers or toes turn blue or black Blood clots Raynouds disease AHN PAIN FISHERS (05/2012) pg 5 of 9

Gastrointestinal Weight loss Stomach pain Nausea Vomiting blood Dark coffee-ground like bowel movement Blood from your rectum Diarrhea Incontinence of stool Constipation How often do you usually have a bowel movement? Every days When was your last rectal and colon examination? Do you consume alcoholic beverages? Lymphatic Swollen glands Muscles and Joints Swollen joints: Which ones? Painful knots in muscles Feel stiff in the morning Urinary Trouble urinating Bladder examination Leak urine when you cough or strain Bladder testing Blood in urine History of incontinence Pain from flank into scrotum or labia Pain when urinating Trouble with bladder control (i.e. incontinence) Awaken nightly to urinate: How many times a night? Reproductive (Male) Unable to have an erection Unable to ejaculate Reproductive (Female) Last menstrual period Could you be pregnant? Yes No Pain around your reproductive organs Skin Rash Sores that are not healing Bruise easily Tears easily Immune Frequent infections Where? Exposed to HIV AHN PAIN FISHERS (05/2012) pg 6 of 9

Please check only one (1) answer for each question. 1. Pain comes and goes and is mild Pain is mild and does not vary Pain comes and goes and is moderate Pain is moderate and does not vary much Pain comes and goes and is severe Pain is severe and does not vary much 2. You do not change personal care habits to avoid pain You do not change personal care habits even though it causes some pain Personal care increases pain level, but you do not change your habits You have to change personal care habits to avoid pain You are unable to do some personal care habits without help You are unable to wash or dress without help 3. Can lift heavy weights with no pain Can lift heavy weights with extra pain Cannot lift heavy weights off the floor Can lift heavy weights from a table but not the floor Can lift only light weights from a table Can only lift very light weights 4. Pain does not prevent walking any distance Pain with walking that does not increase with distance Cannot walk more than one mile Cannot walk more than 1/2 mile Bedridden and must crawl to the toilet 5. Can sit in any chair as long as desired without pain Can sit only in a favorite chair as long as desired Can sit no more than one hour Can sit no more than 1/2 hour Can sit no more than 10 minutes Cannot sit at all due to pain AHN PAIN FISHERS (05/2012) pg 7 of 9

6. Can stand for an unlimited time without pain Some pain with standing but does not increase with time Cannot stand for more than one hour without pain increasing Cannot stand for more than 1/2 hour without pain increasing Cannot stand for more than 10 minutes without pain increasing Cannot stand at all 7. No pain in bed Pain in bed, but you still get a good night s sleep Normal night s sleep reduced by 1/4 Normal night s sleep reduced by 1/2 Normal night s sleep reduced by 3/4 Cannot sleep at all due to pain 8. Travel without pain Travel causes extra pain, but not made worse Travel causes extra pain / no change in form of travel Travel causes extra pain / use alternative forms of travel Pain restricts all forms of travel Pain restricts travel except lying down 9. Social life is normal and causes no pain Social life is normal but causes extra pain Pain limits your energetic interests Social life is limited; don t go out as often Severely affected by pain; have no social life at all 10. Pain is rapidly improving Pain fluctuates but is improving Improvement is slow Pain level is unchanged Pain is gradually worsening Pain is rapidly worsening AHN PAIN FISHERS (05/2012) pg 8 of 9

Please shade areas where you have pain AHN PAIN FISHERS (05/2012) pg 9 of 9

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