1 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.
2 No pain pain worst imaginable Rate your pain by circling the one number that best describes your pain at its least: 0 1 2 3 4 5 6 7 8 9 10. No pain pain worst imaginable Rate your pain by circling the one number that best describes your pain on the average: 0 1 2 3 4 5 6 7 8 9 10. No pain pain worst imaginable Page 1 of 5. What makes pain worse: _____. What makes pain better: _____. Time of the day when pain is worse:_____. Do you have the following?: Weakness in your: arms right left legs right left Numbness in your: arms right left legs right left New or recurrent problems with bowel or bladder control? Yes no Change in pain with cough/sneeze/bowel movements? Yes no Medication HISTORY Indicate what you have used for your current pain condition: If you have tried any of the listed medications, please indicate whether it helped with your pain or not by checking the appropriate box.
3 If you have not tried an agent, check never tried . Narcotics/Opiates: Did it help? Yes/No Never tried Butrans Patch Codeine (Tylenol #3). Fentanyl Patch (Duragesic). Hydrocodone (Vicodin, Norco). Hydromorphone (Dilaudid,Exalgo). Morphine (Kadian, MS Contin). Methadone Nucynta Oxycodone (Oxycontin). Oxymorphone (Opana). Tramadol (Ultram). Other/Comments:_____. Antiinflammatories: Did it help? Yes/No Never tried Aspirin Celebrex (Celecoxib). Diclofenac (Voltaren). Etodolac (Lodine). Ibuprofen (Motrin, Advil). Indomethacin Meloxicam (Mobic). Naproxen (Aleve, Naprosyn). Nabumetone (Relafen). Tylenol Other/Comments:_____. Antineuropathics: Did it help? Yes/No Never tried Amitriptyline Duloxetine (Cymbalta). Gabapentin (Neurontin). Milnacipran (Savella). Nortriptyline Pregabalin (Lyrica). Topiramate (Topamax).
4 Other/Comments:_____. Muscle Relaxants: Did it help? Yes/No Never tried Baclofen Carisoprodol (Soma). Chlorzoxazone (Lorzone). Cyclobenzaprine (Flexeril). Metaxalone (Skelaxin). Methocarbamol (Robaxin). Tizanidine (Zanaflex). Other/Comments:_____. Page 2 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. If you have not tried an agent, check never tried . Treatment: Did it help? Yes/No Never tried Physical Therapy Chiropractic TENS Unit Acupuncture Trigger Point injections Joint injections Facet block/Medial Branch Block Epidural Steroid Injection Radiofrequency Ablation Spinal Cord Stimulator Psychiatric/Psychological care Other/Comments:_____. Name of prior pain Physician(s): _____. Are you currently taking Anticoagulants/Blood Thinners?
5 Yes/No If yes, what type? Warfarin/Coumadin Aspirin Lovenox Other_____. Plavix (Clopidogrel) Eliquis Heparin Pradaxa Arixta Herbals (Garlic, Ginko, Ginseng, Vitamin E). Why are you taking a blood thinner?_____. Diagnostic Studies: X-Ray Yes No MRI Scan Yes No CT Scans Yes No Bone Scan Yes No EMG/NCS Yes No Other _____. Past Medical HISTORY : Cardiac High Blood Pressure Congestive Heart Failure Heart Attack Angina/Chest pain Coronary Artery Disease Irregular Heartbeat Heart Murmur Cardiac Stents Pacemaker /AICD Blood Thinners Valvular Disease Vascular Disease Pulmonary COPD Emphysema Asthma Lung Cancer Sleep Apnea Bronchial Disease Tobacco Renal Dialysis Renal Insufficiency Kidney Stone Prostate Problems Neurological Stroke Transient Ischemic Attack Seizures Nerve Damage Infectious Valley Fever Tuberculosis HIV/AIDS Polio Hepatic Liver Disease Cirrhosis Hepatitis Gall Bladder If you have Hepatitis, please specify what type (if known):_____.
6 Gastrointestinal Hiatal Hernia GERD Gastric Ulcers Colitis Page 3 of 5. Endocrine Thyroid Disease Parathyroid Disease Diabetes Mellitus Psychological Depression Bipolar Addiction Schizophrenia General Anemia/Bleeding Arthritis Obesity Alcoholism Past Surgical HISTORY (be as specific as possible, including surgery type and year of surgery): 1. 4. Serious Injury: List serious injuries you have sustained: _____. Allergies to Medications: Yes No (if yes, indicate below drug and reaction). Drug Reaction _____ _____. _____ _____. _____ _____. Current Medications (Include vitamins, antacids, birth control, etc., attach list if necessary): Name: Dose: How often: 1. _____ _____ _____. 2. _____ _____ _____. 3. _____ _____ _____. 4. _____ _____ _____. 5. _____ _____ _____. 6. _____ _____ _____. Family HISTORY : _____.
7 Is there any HISTORY of drug/alcohol abuse/addiction in your family? Yes No Social HISTORY : Occupation: _____. Are you currently working? Yes No Part-time Full-time Education: Elementary High school College Graduate school Marital Status: Married Widowed Divorced Single Significant Other Children: Y/N If yes, how many? _____. Do you have any lawsuits pending or planned? Yes No Are you on disability? Yes No Workmen's Comp? Yes No Tobacco use: Current Former Never If current: #of packs per day _____ How many years? _____. Alcohol: Do you consume alcohol? Yes No If Yes: Approximate #of drinks per day _____ How many years?_____. Illicit/Street Drugs: Do you use any illicit/street drugs? Current Former Never If current/former: What drugs?_____. Have you ever been in treatment for drug or alcohol problems? Yes No Do you currently use Medical Marijuana?
8 Yes No Page 4 of 5. Review of Systems (List only current or very recent symptoms): General: Weight Change Fatigue Weakness Fever Loss of Appetite Chills No Problems Cardiac: Chest pain /Angina Shortness of Breath Palpitations Peripheral Edema No problems Endocrine: Heat intolerance Excessive sweating Excessive urination Cold intolerance Excessive thirst No problems Gastrointestinal: Diarrhea Reflux Constipation Change in appetite Abdominal pain Nausea Loss of bowel control Blood or Black Stool Vomiting No Problems Genitourinary: Difficulty Urinating Painful Urination Blood in urine Loss of Bladder Control No Problems HEENT: Sinus Problems Difficulty Swallowing Headache Jaw Problems Dry Mouth Migraines Mouth Problems No Problems Hematology/ Chemotherapy HISTORY Bleeding Disorder No Problems Oncology: Radiation HISTORY Anticoagulation Therapy Musculoskeletal: Muscle Cramps Joint Stiffness Muscle atrophy Joint Redness Joint Swelling No Problems Joint Heat Neurological: Blackouts Weakness Numbness Fainting Paralysis Gait Difficulties Hallucinations Dizziness No Problems Tremors Confusion Opthalmology: Blurred Vision Eye pain No Problems Double Vision Photophobia (light is painful).
9 Psychiatric: Depression Suicidal Ideation Anxiety Drug Abuse Homicidal Ideation No Problems Respiratory: Cough Shortness of Breath Wheezing Hemoptysis No Problems Skin: Dry Skin Changes in Hair or Nail Eczema Changes in Skin Color Recurrent Rashes No Problems Itching Toxins: Asbestos Industrial Chemicals Lead Pesticides Drug Use No Problems _____ _____/_____/_____. PATIENT Signature Date Reviewed by: _____ _____/_____/_____. Provider Signature Date Page 5 of 5. PATIENT REGISTRATION FORM. Date_____. PATIENT 's Name_____. Address_____. City _____State _____Zip Code_____ email _____. Home Phone (___) _____ Mobile (___) _____ Work Phone (___) _____. Social Security #_____ Date of Birth_____ Sex _____Marital Status_____. Referring Physician_____Phone_____. Primary Care Physician_____Phone_____. PATIENT 's Employer _____.
10 Employer Address_____. Responsible Party Information Self _____ Spouse _____ Parent _____ Other _____. Guarantor's Name_____. Address_____. City _____State _____Zip Code_____. Home Phone (___) _____ Mobile (___) _____ Work Phone (___) _____. Relationship to PATIENT _____Date of Birth _____Social Security #_____. Guarantor's Employer _____Work Phone (_____) _____. Employer Address_____. Emergency Contact Information Name_____Relationship_____. Address_____. Home Phone (___) _____ Mobile (___) _____ Work Phone (___) _____. Insurance Information Primary Carrier: Name _____Group #_____. Address_____. Policy Holder's Name _____Relationship to Patient_____. Policy Holder's Date of Birth_____ Social Security #_____. Policy #_____. Secondary Carrier: Name _____Group #_____. Address_____. Policy Holder's Name _____Relationship to Patient_____.