Transcription of NEW PATIENT HEALTH HISTORY AND PAIN ... - …
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NEW PATIENT HEALTH HISTORY AND PAIN ... - …
NEW PATIENT HEALTH HISTORY AND. pain QUESTIONNAIRE. PATIENT Name: _____Age _____. Male Female Right handed Left handed Ambidextrous HISTORY of Problem for which you are being seen: Reason for visit: _____. By whom were you referred to our practice?_____. Expectations from treatment:_____. Type of injury: Job Accident Sports Injury Other: _____. Car accident: Driver Passenger Seat-belted: Yes No Airbag: Yes No Date injury/symptoms started: _____. Do you have cancer? Yes No Cancer Type/Stage: _____. How would you describe your mood in a word or two? _____. On the diagram below, shade the areas where you feel pain . Put an x where it hurts the most;. check all terms that apply. Aching Burning Stabbing Shooting Constant Transient Sharp Dull Mild Moderate R L L R. Severe Unbearable Numbness Tingling Rate your pain by circling the one number that best describes your pain at its worst: 0 1 2 3 4 5 6 7 8 9 10.
Page 3 of 5. TREATMENT HISTORY: If you have tried any of the listed treatments, please indicate whether it helped with your pain or not by checking the appropriate box.
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