PAIN TREATMENT CENTER

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Transcription:

PAIN TREATMENT CENTER Name Date Age Occupation Referring Doctor Have you ever been a patient of a Pain Clinic or Center? Yes No If yes where: When did you first notice symptoms of your pain problem? Date Day of week Time of day What type of activity were you doing? Where were you when the pain began? Is your pain related to an injury? Yes No Type of injury: Work related Vehicle accident Other Are you planning to sue because of your pain/injury? Yes No Have you already sued because of your pain? Yes No Description of injury Where was your pain located when it BEGAN? Where is your pain located NOW? Describe your pain. Aching Shooting Burning Squeezing Numb Stabbing Sharp Throbbing Shocking Tingling Other: Does your pain move to different areas? Yes No (If yes) Where does your pain move? Pain is worsened by: Lying Stairs Sitting Bending Standing Changes in Position (Sitting to Standing) Walking Other: Pain is better with: Rest Changes in Position Lying Medication Sitting Other: Standing Duration of Pain: 0-3 months 3-6 months 6-12 months 1-2 years More than 2 years Timing of Pain: Constant Intermittent (comes and goes) Worse in Morning Worse in Evening

Check all that apply: Abnormal or decreased feeling to touch or temperature Unable to move your arm, leg or another part of your body Loss of coordination Change in skin color Change in skin temperature Hotter Colder If so to any of the above, where: To your right are drawings that will help you describe where your pain is located. Please color or shade in the areas on the drawings that best describe where your pain is now. Below is a line to help you describe the level of your pain. 0 means no pain and 10 means the worst pain you ever had. CIRCLE a number to describe your pain TODAY. Severity of pain: 0 1 2 3 4 5 6 7 8 9 10 None Mild Moderate Severe Very Worst Severe Possible How often do you have pain: Always present/ Always the same level Always present but level changes Occasional pain Periods free of pain Rarely present (only a few days OR weeks) Does your pain limit your activities? Yes N0 I can look after myself without causing extra pain I can look after myself but it causes extra pain I need help to dress, bathe and do personal care I can walk: Without pain A mile but with pain ½ mile but with pain ¼ mile but with pain Only with crutches, a cane or walker I am in bed most of the time I can stand: As long as I want But only with pain But less than 1 hour without pain But less than 30 minutes without pain But less than 10 minutes without pain Cannot stand at all due to pain Sleep problems:

None Restlessness Difficulty falling asleep Sleep Apnea Difficulty staying asleep *LIST ANY DRUG ALLERGIES *Are you ALLERGIC to any LATEX (rubber gloves/plastics) products? YES NO *Are you currently taking any Blood Thinners? ASPIRIN COUMADIN PLAVIX AGGRENOX EFFIENT PRADAXA PLETAL OTHER Who prescribes this drug for you? Do you bruise easily? Yes No *DO YOU HAVE A LIVING WILL FOR HEALTH CARE? Yes No Past and Present Medical History Check the boxes if you NOW have or EVER HAD: Cardiovascular Hematology Angina Bleeding problems Arrhythmia (Irregular heart beat) Blood clots Chest Pain Anemia Heart attack HIV/AIDS Heart Murmur Mitral Valve Prolapse Endocrinology Congestive Heart Failure Diabetes High Blood Pressure Thyroid Problems Stroke Neurological Dizziness Respiratory Weakness Sleep Apnea Numbness COPD Seizures (date of last seizure) Chronic cough Syncope/Fainting Emphysema/Bronchitis Loss of coordination Shortness of breath Loss of balance Coughing up blood Blackouts Musculoskeletal Head/Ears/Eyes/Nose/Throat Arthritis Sinus congestion Back pain/stiffness Glaucoma Joint pain/stiffness Contacts Fibromyalgia Hearing loss Gastrointestinal Ringing in the ears Hepatitus Reflux disease Blurred vision Stomach ulcers Glasses Abdominal pain Sore throat Diverticulitis Difficulty swallowing Heartburn Hearing aid Nausea/vomiting Psychological Diarrhea Anxiety

Constipation Depression Black Stools Suicidal attempt or thoughts Bloody stools Frequent feelings of sadness Weight loss Crying spells Appetite change Treatment with antidepressant Genitourinary medications Difficulty urinating (If so) Is current medication helpful? Urinary Tract Infections Yes No Inability to control Urination (incontinence) Have you ever had psychological or Cancer Psychiatric treatment? Yes No Yes No Where? Other medical problems Do you have any implants in your body? Pacemaker Heart stents Lens implants (eye) Breast Implants Cervical (neck) Hardware Lumbar (back) Hardware Plates/Pins/Wires/Clips Artificial Joints Other Surgical History Enter Date, if known, and check if you have had: Back surgery Gallbladder surgery Neck surgery Heart surgery Hip surgery Bypass Tonsillectomy Valve replacement Appendectomy Heart Stents Hernia Repair Brain surgery Sinus Surgery Hysterectomy Stomach surgery C-section Cystoscopy Tubal ligation Other Have you ever had problems with anesthesia or sedation? Yes No Describe: Has anyone in your family ever had problems with anesthesia or sedation? Yes No Describe Previous treatments/tests Have you had any of the following treatments for your pain? Helped Helped Did Not Made a lota little help worse Hypnosis Biofeedback TENS unit Acupuncture Chiropractor Physical Therapy Traction therapy Massage therapy Lumbar Spine surgery Cervical Spine Surgery Medication Related to your current pain condition, have you had: X-rays Bone scan Other CT scans Blood test Where: MRI Nerve test When: Occupational/Family/Social History Are any of your family members receiving disability: Yes No Has anyone in your family ever had a problem like yours? Yes No

Marital status: Single Married Widowed Separated Divorced Total number of children? Number 2 yrs old or under Number 3 to 6 Number of teenagers Number of adult children Has your pain stopped you from working? Yes No (If yes) Unable to do any work Can work limited amounts (short periods/light duty) Describe the type of work that you do: None Heavy lifting Constant strain Standing most of the time Sitting most of the time Frequent bending/turning Do you smoke? Yes No 1/2 pack a day 1pack a day 2 packs a day more than 2 packs a day Do you drink alcohol? Yes No Seldom ( 1 or 2 per week) ( 3 or more times per week) Every day ( 1 per day) ( 2-3 per day) ( More than 3 per day) Have you ever used unprescribed drugs? Yes No Marijuana Cocaine Amphetamines Opioids (narcotics) Have you been treated for Drug or Alcohol abuse or addiction? Yes No If yes: When: Where: Medication History Pharmacy location Current medications: Drug Amount/Dosage Times each day Prescribed by Dr: Patient s signature RN signature Physician signature

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