COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:

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COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name of Family Physician: Phone: Fax: Address: City: State: Zip: 1. When did your pain start? 2. What caused your pain? Accident Other Disease No obvious cause Cancer Surgery (specify) 3. Describe in your own words the pain problem(s) that you would like help with: - 1 -

4. How often does your pain occur? How long does your pain last? Continuous Continuous Several times a day Weeks Once a day Days Several times a week Hours Once a week Minutes Less than once a week Seconds Never None 5. Below is list of words that might describe your pain. Circle all that apply: Throbbing Shooting Stabbing Sharp Cramping Gnawing Sickening Punishing-Cruel Hot-Burning Aching Heavy Tender Splitting Tiring-Exhausting Fearful Other: 6. Circle the number below to indicate your highest pain intensity over the past week: None Mild Moderate Severe Most 7. Circle the number below to indicate your lowest pain intensity over the past week: None Mild Moderate Severe Most 8. Circle the number below to indicate your usual pain intensity over the past week: None Mild Moderate Severe Most 9. Circle the number below to indicate how much your pain interferred with your activities this week: None Mild Moderate Severe Completely 10. What makes your pain better? Sitting Standing Walking Bending Lying Down Driving Coughing/Sneezing - 2 -

11. What makes your pain worse? Sitting Standing Walking Bending Lying Down Driving Coughing/Sneezing 12. Please indicate where you have pain by marking the areas on your body. 13. Have you had any of the following tests to evaluate your pain? (please provide details) X-Rays MRI CT Scan Myelogram EMG Blood Tests Bone Scan Discogram 14. Do you have any of the following conditions associated with your pain? (indicate all that apply): Bowel/Bladder Incontinence Muscle Weakness Numbness/Tingling/Pins/Needles - 3 -

15. Please indicate any previous treatments you have tried for your pain and whether they helped your pain: Yes No Accupuncture Chiropractor Biofeedback Traction TENS Unit Physical Therapy Massage Psychologist Psychiatrist Alternative Medicine Surgery Medications Epidurals 16. Past Medical History Yes No Yes No Arrythmia Liver Disease High Blood Pressure Hepatitis Angina/Heart Disease Kidney Disease Heart Attack Ulcers Heart Failure Acid Reflux Emphysema/Asthma Other GI Illness COPD Bleeding Disorder Stroke Taking Blood thinners Seizures Thyroid Disease Cancer HIV Arthritis Irritable Bowel Disease Diabetes Skin Condition Migraine Headaches Depression Psychiatric Illness Other: 17. Past Surgical History (please indicate type of surgery, date and physician s name) Surgery Date Surgeon 18. Do you have any allergies to medications? - 4 -

19. Current Medications: Name Dose How Many Times a Day 20. What is your mood like now? Worst Poor Fair Good Best 21. Do you have problems with any of the following? (check all that apply) Yes No Yes No Sleep Concentration Mood Anxiety Depression Suicidal thoughts Self-worth Homicidal thoughts 22. Family History Mother: Living/Deceased Cause: Father: Living/Deceased Cause: Siblings: Living/Deceased Cause: Siblings: Living/Deceased Cause: 23. Social History Relationship Status Married Divorced Widowed Single Separted Domestic Partnership With whom do you live? Self Spouse Children Parents Friends Other: - 5 -

What is your current employment status? Employed full-time Self-employed Homemaker Unemployed due to other reason. Employed part-time Retired Unemployed due to pain Are you on disability? Yes No Y. Do you have an attorney or legal action pending related to this pain or any other health problems? Yes No If so, please list attorney s name: Do you drink alcohol? Yes No If so, specify Do you smoke? Yes No If so, specify Do you currently or have you ever abused recreational drugs? Yes No If so, specify: 24. Do you experience any of the following? Review of Symptoms (please indicate all that apply): Yes No Yes No Fever Weight Loss Night Sweats Swelling Rash Cough Sputum Production Shortness of Breath Wheezing Chest Pain Chest Pain Palpitations Abdominal Pain Constipation Diarrhea Black bowel movement Blood in stool Nausea Headache Lightheadness Dizziness Vision Changes Easy Bruising Urinary Frequency Difficulty Urinating Pregnancy Bowel or Bladder Incontinence Weakness/Paralysis of the arms and legs - 6 -

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