General Information Name (First, Middle initial, Last): Mailing Address: Home phone: Cell Email Gender identification: M F Birthdate: Age: Birthplace: Nationality: Religion: Marital Status: Ages of children (if any) Education completed Work status: Employed Homemaker Student Retired SSD/SSI On Workers Comp Your occupation: Spouse occupation: Pain-Related Issues What would you like to change? In what parts of your body do you experience significant pain (circle all that apply)? Whole or most of body Head Neck Back Shoulders or arms Chest/breasts Knees Hips, buttocks or legs Pelvis/genitals Other (specify) How long have you experienced significant chronic pain? (cc 0020ircle) Less than 2 yrs 2+ to 5 yrs 5+ to 10 yrs 10+ to 20 yrs More than 20 years Please indicate if the onset of your pain was associated with any of the following (circle all that apply): Disease process Surgery Cancer Work accident Car accident Sports injury Other accident or injury Just started out of the blue Other Please describe what happened: CPRC-001 CPRC-Pt. Self Evaluation Record Page 1 of 6
Please mark the diagram with the locations of your pain or other distressing sensations: Please label each area you have marked with a descriptor(s) of the sensation, as examples: burning, tingling, sharp, stabbing, squeezing, tight, cold, electrical, aching, throbbing, numb etc. Please label each area you have marked with time description, as examples: constant, intermittent, rhythmic, fleeting, continuous, etc. What makes your pain worse? What relieves your pain? How does your pain change over the course of a day? Please rate the intensity of your pain over the past week: No pain 0 1 2 3 4 5 6 7 8 9 10 Worst pain possible Worst pain 0 1 2 3 4 5 6 7 8 9 10 Least pain 0 1 2 3 4 5 6 7 8 9 10 Typical pain 0 1 2 3 4 5 6 7 8 9 10 Has your pain changed in location or intensity over the past year? (circle) Yes No If so, how? CPRC-001 CPRC-Pt. Self Evaluation Record Page 2 of 6
How much does your pain interfere with the following Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes Marriage/primary relationship 0 1 2 3 4 5 6 7 8 9 10 Ability to parent your children 0 1 2 3 4 5 6 7 8 9 10 Work or school 0 1 2 3 4 5 6 7 8 9 10 Physical conditioning & fitness 0 1 2 3 4 5 6 7 8 9 10 Leisure & social activities 0 1 2 3 4 5 6 7 8 9 10 Relationships with friends 0 1 2 3 4 5 6 7 8 9 10 Restful nights sleep 0 1 2 3 4 5 6 7 8 9 10 Mood 0 1 2 3 4 5 6 7 8 9 10 Enjoyment of life 0 1 2 3 4 5 6 7 8 9 10 Sexuality 0 1 2 3 4 5 6 7 8 9 10 Please list all medications are you currently taking for pain and for other problems. (Include prescribed, over the counter and herbal or nutritional preparations) Medication Dose Frequency Purpose Medication Dose/Frequency Purpose What other treatments or management strategies are you currently using to help your pain? ( for example injections, relaxation/meditation, pacing activities, ice/heat, exercise, stretch, support groups etc) \ CPRC-001 CPRC-Pt. Self Evaluation Record Page 3 of 6
Please indicate who currently your prescribes your pain medication Please indicate other providers who are currently treating or following you for your pain and/or related problems Please indicate providers what have assessed or treated you pain in the past (name, location and year if known) Name Location Year seen Primary care Pain specialist Physiatrist Orthopedist Neurologist Neurosurgeon Rheumatologist Chiropractor Other (specify specialty) What types of treatments have you had for your pain? (Check all that apply & check column indicating how helpful) Physical therapy Exercise (pool, land based) Medical weight loss Surgery Counseling/stress management Outpatient psychiatric treatment Injections (please specify types) Acupuncture Massage Chiropractic Other (please specify) Not helpful Somewhat helpful Very helpful CPRC-001 CPRC-Pt. Self Evaluation Record Page 4 of 6
Please indicate what studies you have had for your pain (where and approximate year): Where done Year done MRI/CT scan Plain xrays EMG/NC studies Other General Health Please list all allergies: (to what and reaction) No allergies Please specify any chronic or recurring medical conditions or symptoms or concerns you have: Respiratory/breathing/pulmonary Cardiac/circulation/blood flow Gastrointestinal/urinary/male-female Musculoskeletal/skin Neurological/brain/nervous system Mental health, substance or addiction problems Other Please list all surgeries you have had for pain and other problems, include surgeon & approximate year Have you experienced any significant trauma in your life, as a child or as an adult? (For example: physical, sexual, or emotional abuse, combat, assault, frightening accident or other?) Yes No If yes, have you ever discussed these experiences with a therapist or other provider? Yes No Please list any inpatient psychiatric or substance treatment admissions, reason for admission, hospital & year CPRC-001 CPRC-Pt. Self Evaluation Record Page 5 of 6
Family health history Please list your parents and siblings ages, if alive, and indicate any health issues they may have. If deceased, please indicate age and cause of death. Has anyone in your family had a substance-related problem? Yes No If yes, please indicate relationship to you and nature of problem. Your health-related activities What do you do for fun or enjoyment? What are your passions? How often do you currently exercise? What do you do for exercise? Do you follow any special diet? If so, what? Do you practice meditation, deep relaxation or stress reduction techniques regularly? Yes No If yes, what type? Please indicate how often and how much of the following you use: Caffeine Alcohol Tobacco Marijuana Cocaine Opioids/narcotics (other than prescribed) Other street drugs Please share any other information you feel is of importance: CPRC-001 CPRC-Pt. Self Evaluation Record Page 6 of 6