PAIN SOLUTIONS NEW PATIENT QUESTIONNAIRE

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Transcription:

PAIN SOLUTIONS NEW PATIENT QUESTIONNAIRE Patient Name: DATE Primary Doctor: Referring Doctor: Please show the location of your pain by drawing on the figures below:

Pain History (PLEASE FILL IN THE BUBBLES) 1. WHERE IS YOUR PAIN LOCATED? O Low Back O Neck O Mid-back O Face O Head O Right arm O Left arm O Right leg O Left leg 2. WHERE DOES THE PAIN RADIATE? O Right leg O Left leg O Both legs O Right arm O Left arm O Both arms O Other 3. THE PAIN FIRST STARTED: O 1 O 2 O 3 O 4 O 5 O 6 O 7 O 8 O 9 O 10 O days ago O weeks ago O months ago O years ago O other Was there an accident or injury that caused the pain? O NO O YES 4. HOW WOULD YOU DESCRIBE YOUR PAIN? (mark all that apply) O aching O throbbing O sharp O dull O nagging O shooting O burning O numb O tingling O stabbing O Other 5. RATE YOUR PAIN AT IT S WORST IN THE LAST 24 HOURS? 0 1 2 3 4 5 6 7 8 9 10 Worst Pain Pain Imaginable 6. RATE YOUR PAIN AT IT S BEST IN THE LAST 24 HOURS? 0 1 2 3 4 5 6 7 8 9 10 Worst Pain Pain Imaginable 7. HOW SEVERE IS YOUR PAIN ON AVERAGE? 0 1 2 3 4 5 6 7 8 9 10 Worst Pain Pain Imaginable 8. HOW MUCH DOES THE PAIN INTERFERE WITH YOUR ACTIVITIES? 0% 10 20 30 40 50 60 70 80 90 100% Completely Interference Interferes 9. HOW MUCH DOES THE PAIN INTERFERE WITH YOUR SLEEP? 0% 10 20 30 40 50 60 70 80 90 100% Completely Interference Interferes 10. THE PAIN IS: O constant O intermittent O worse in am O worse in afternoon O worse in evening O worse at night 11. WHAT MAKES THE PAIN WORSE? O standing O walking O sitting O lifting O bending over O other 12. WHAT MAKES THE PAIN BETTER? O standing O walking O bending

O lifting O sitting O lying down O ice O heat O medications O other 13. IN ADDITION TO THE PAIN, DO YOU HAVE? O Numbness O Weakness O In the right arm O In the left arm O In both arms O In the right leg O In the left leg O In both legs O New bladder incontinence O New bowel incontinence O ne of these 14. IS YOUR PAIN: O getting better O getting worse O staying about the same 15. WHAT TESTS HAVE YOU HAD FOR YOUR PAIN? (Please list date of last exam) O X-rays O MRI Scan O CT Scan O EMG O Other 16. WHAT MEDICATIONS HAVE YOU TRIED FOR YOUR PAIN? (Check ALL that apply) Anti-Inflammatory: O Ibuprofen (Advil, Motrin) O Naproxen O Celebrex O Aspirin O Relafen O Meloxicam (Mobic) O Indomethicin Narcotic: O Morphine O Avinza O MSIR O MS Contin O Kadian O Dilaudid O Oxycodone O Oxycontin O Percocet O Percodan O Darvocet O Darvon O Hydrocodone O Vicodin O Lortab O Lorcet O rco O Fentanyl O Duragesic O Actiq O Fentora O Codeine O Tramadol O Ultram O Stadol Antidepressants O Duloxetine (Cymbalta) O Fluoxetine (Prozac) O Escitalopram (Lexapro) O Trazodone (Deseryl) O Venflaxine (Effexor) O Sertraline (Zoloft) O Amitriptyline (Elavil) O rtriptyline (Pamelor) O Desipramine (rpramine) O Buproprion (Wellbutrin) O Citalopram (Celexa) O Paroxetine (Paxil) O Nefazodone (Serzone) Anti-Seizure O Gabapentin (Neurontin) O Pregabalin (Lyrica) O Zonisamide (Zonegram) O Carbamazepine (Tegretol) O Lamotrigine (Lamictal) O Oxycarbazepine (Trileptal) O Tiagabine (Gabatril) O Topiramate (Topamax) Muscle Relaxants/ O Baclofen (Lioresal) O Tizanidine (Zanaflex) O Metaxolone (Skelaxin) Anti-Anxiety O Cyclobenzaprine (Flexeril) O Methocarbamol (Robaxin) O Carisoprodol (Soma) O Diazepam (Valium) O Clonazepam (Klonopin) O Alprazolam (Xanax) Sleeping Aids O Zolpidem (Ambien) O Eszopiclone (Lunesta) O Zalepion (Sonata) O Trazodone (Deseryl) O Amitriptyline (Elavil) O Temazepam (Restoril) O Triazolam (Halcion) O Tylenol PM Other Pain Meds O Lidoderm Patch O Flector Patch O Topical Gel O Mirapex

17. WHAT TREATMENTS HAVE YOU HAD FOR YOUR PAIN? O Physical therapy O Water Therapy O Traction O Exercise O Yoga O Psychology O Acupuncture O Chiropractic O Massage O TENS O Biofeedback O Hypnosis O Rolfing O Trigger Point Injections O Facet Injections O Epidural Injections O Nerve Blocks O Spinal Pump O Spinal Cord Stimulator O Other Past Medical History (Please Fill in yes or no to all questions) CARDIOVASCULAR Cardiac Arrythmia Heart Attack Coronary Artery Disease Atrial fibrillation Mitral Valve Prolapse Congestive Heart Failure High Blood Pressure High Cholesterol DVT (blood clot) RESPIRATORY Asthma COPD - Emphysema Sleep apnea NEUROLOGY TMJ Seizures Trigeminal Neuralgia Headache - Migraines Headache - Tension Headache - Cluster Post-herpetic Neuralgia Multiple Sclerosis Myasthenia Gravis Stroke PSYCH Anxiety/depression Bipolar Disorder Schizophrenia Dementia GASTOINTESTINAL Irritable bowel syndrome Peptic ulcer disease Indigestion/acid reflux Hiatus hernia Hepatitis B Hepatitis C Ulcerative Colitis OTHER Kidney stones Kidney Failure Kidney Disease Hypothyroidism Lupus Cancer What kind? Osteoporosis Fibromyalgia Arthritis - Rheumatoid Osteoarthritis RSD Anemia Diabetes(insulin) Diabetes(no insulin) Social History

Do you drink Alcohol? O O Yes O Occasionally O daily O weekly Do you smoke? O O Yes O <1ppd O 1ppd O 2ppd O 3ppd Do you exercise? O O Yes Do you work? O O Yes O Full-time O Part-time O Unemployed due to pain O Homemaker O Retired Occupation Do you use Illegal Drugs? O O Yes O Used in the past Drug(s) Used OTHER SYMPTOMS (Please indicate other symptoms you may have) CONSTITUTIONAL Fever Fatigue Insomnia Weight loss Weight gain Loss of Appetite GI Abnormal bruising Abnormal bleeding NEUROLOGY Seizures Headache Memory loss Numbness Where? Blood in stool Diarrhea Vomiting Constipation Nausea Difficulty swallowing Abdominal pain Heartburn URINARY Urinary retention Incontinence RESPIRATORY Wheezing CARDIOVASCULAR Dizziness Chest pain Palpitations Leg swelling Shortness of breath ENT Cough MUSCULOSKELETAL Joint pain Joint stiffness Back pain Muscle weakness PSYCH Depression Sleep disturbances Suicidal ideation Anxiety HEMATOLOGY

CURRENT MEDICATIONS (Include dosage and # tablets per day) Have you had any surgeries? Are you taking any of the following blood thinners? Coumadin Plavix Do you have any allergies to medications? Latex Iodine Other Medications? What are your goals for your pain treatment? Are there any specific treatments that you would like for your pain? Medications: Physical Therapy: Exercise: Psychologist referral: Surgery referral Injections: Other pain therapies: (Please circle) acupuncture chiropractic massage TENS DRX9000 Pool exercise biofeedback Other Do you have a driver with you today? yes no THIS IS THE END OF THE QUESTIONNAIRE. THANK YOU!

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