New Patient Intake Form. Please List All Current Medications. Please shade in the areas where you have pain

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Transcription:

New Patient Intake Form Name: Date: Referring Physician Primary Care Physician Please List All Current Medications Do you take Coumadin/Warfarin/Plavix/Lovonox or Aspirin? Yes No Last dose? Please shade in the areas where you have pain Characteristics of your pain Pain Intensity (0 no pain, 10 worst pain ever) Associated Systems please circle if applies to you Please list number that best describes you pain I do not have any other symptoms Average Pain Fatigue Worse Pain Loss of bowel/bladder control With Activity Nausea Numbness Tingling, burning, or pricking feeling Spasm Weakness

Circle activities that make pain worse All Activities Bending Forward Exertion/Exercise Getting out of chair Lifting Lying Down Moderate Physical activity Nonspecific activity Position Change Reaching Significant Physical Activity Sitting Standing Turning the Head Twisting Walking Other Circle things activities that make pain better None Bending Forward Injections Lying down Medications Moving Position Change Physical Activity Procedures Rest Sitting Standing Other Circle the qualities of your pain Aching Burning Dull Sharp Shooting Stabbing Throbbing Pressure Crushing Cramping Spasmodic Pulling Tender Tight Knife like Hot Sore Circle the duration of your pain Constant Intermittent If you are allergic to anything please list below:

Circle any conditions you have Headaches Gallstones Hepatitis Bladder Cancer Migraines GERD HIV Breast Cancer Seasonal Allergies GI Bleed Shingles Colon Cancer Sinusitis Hiatal Hernia Lung Cancer Irritable Bowel Syndrome Stroke Melanoma Angina Pancreatitis Parkinson s Disease Prostate Cancer Arrhythmia Ulcers Seizure Disorder Coronary Artery Disease TIA Back Pain Deep Venous Thrombosis Enlarged Prostate Connective Tissue Disorder High Blood Pressure Frequent Bladder Infections ADD Fibromyalgia High Cholesterol Kidney Stones Anxiety Kyphoscoliosis Past Heart Attack Renal Failure Bi polar Disorder Osteoarthritis Mitral Valve Prolapse Renal Insufficiency Dementia Osteoporosis Heart Murmur Depression Rheumatoid arthritis Pacemaker Diabetes Schizophrenia Scoliosis Peripheral Vascular Disease Obesity Thyroid Disease Asthma COPD Obstructive Sleep Apnea Anemia Bleeding Disorder Transfusions List all past surgeries followed by approximate dates 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. Circle Prior Treatments X if it was helpful Details Acupuncture Biofeedback Relaxation Therapy Botox Injections Chiropractic Heat Home Exercise Ice Massage Minimally Invasive Procedures Occupational Therapy Physical Therapy Surgery TENS

Circle all medications taken for your pain in the past X if it helped Details NSAIDS Celebrex Diclofenac Flector Patch Ibuprofen Mobic Nabumetone Naproxen Voltaren gel Flexeril Skelaxin Soma Zanaflex Actiq Hydrocodone Hydromorphine Percocet Duragesic Methadone Morphine Oxycontin Oxymorphine Cymbalta Lyrica Neurontin Savellla Topamax Trileptal Lidoderm Patch Tramadol Tylenol Blood thinners Other Medications

Circle what applies Single Currently smoke every day I never exercise Married Currently smoke some days I exercise 1 2 times per week Domestic Partner Former Smoker I exercise 3 5 times per week Widowed Never Smoker I exercise 6 7 times per week Separated Cigarettes Packs per day Type of Exercise I do: Divorced Cigars per day Aerobics Pipe times per day Biking Number of Children Chew cans per day Running Ages of Children Total years Hiking Swimming Retired No Alcohol Use Climbing Disabled Rarely Use Alcohol Treadmill/Elliptical Unemployed Socially Use Alcohol Walking Self employed Daily Use Alcohol Weight Lifting Employed Part Time Details Other Employed Full Time Current Occupation I do not use recreational drugs Previous Occupation I use Marijuana I use Cocaine Circle Highest Level of Education I use Heroin Elementary Education I use Morphine Some High School I use Methamphetamines High School Diploma I use LSD GED I use Mushrooms Some College I use Ecstasy College Degree I use Master s Degree Doctorate Degree Family History place an X if this relative has the following: Father Mother Sister Brother Other Arthritis Asthma Bleeding Disorder Coronary Artery Disease Cancer Congestive Heart Failure COPD Diabetes High Blood Pressure Irritable Bowel Syndrome Kidney Disease Heart Attack Peripheral Artery Disease Stroke Thyroid Disease Other

Circle if you have the following Depression Anxiety Psychosis Describe: Describe: Describe: Circle what applies I am currently not in treatment I am currently seeing a psychiatrist I am currently seeing a psychologist I have had thoughts of suicide I have not had thoughts of suicide I am coping well with my chronic pain I am frustrated with my chronic pain Circle all that apply to you: Fever Chills Fatigue Poor Appetite Weight Gain Weight Loss Hearing Loss Sore Throat Blurred Vision Decreased Vision Shortness of Breath Wheezing Cough Chest Pain Irregular Heart Beats Swelling in Leg Rash Itching Lesions Bruise Easily Joint Pain Joint Swelling Stiffness Weakness Abdominal Pain Nausea Vomiting Diarrhea Heartburn Constipation Sexual Problems Problems Urinating Headache Dizziness Loss of Consciousness Weakness Numbness Tingling Depression Anxiety

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