Transcription of PAIN QUESTIONNAIRE - Valley Pain Consultants
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PAIN QUESTIONNAIRE - Valley Pain Consultants
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?
Page 3 of 17 Treatment History Indicate the treatment you have received for your current pain condition: 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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