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Severnanesthesiaadvancedpainmedicine.com

CONFIDENTIAL
SEVERN ANESTHESIA ADVANCED PAIN MEDICINE
HEALTH QUESTIONNAIRE

Thank you for arranging to visit one of our physicians.
When you come for your first visit, please bring this completed form along with any medical records, X-rays, CT or MRI
scans, medication bottles and other medical information related to the problem for which you are being seen.
Should you have any questions, please do not hesitate to contact us.
Thank you very much. We look forward to seeing you.
Please complete the attached questionnaire before your
appointment. It is confidential and will be part of your medical
record. It asks for information about your current problems and your past medical history. This form will give your doctor a better understanding of your problem, and will allow him or her to spend more time discussing treatment plans with you.

SEVERN ANESTHESIA ADVANCED PAIN
M E D I C I N E
Admin. office: 301 Hospital Drive Clinic Address: 300 Hospital Drive
Glen Burnie, Maryland 21061 Suite 230
Phone: (410) 553-8056 Glen Burnie, MD 21061
Fax: (410) 595-1907
Mailing Address: PO BOX 403
Millersville, MD 21108

DATE:______________________________
Name:_____________________________________________________________________________________ City____________________________ State________ Zip___________ Primary Care Physician: Name:_______________________________________________
Address:_____________________________________________ ____________________________________________________ # ___________________
List all other Physicians that your records should be sent to: Pain Related Information. Please answer all questions.
1) Describe the event(s) surrounding the onset of your pain. (I.e. date of injury, is it the same or getting worse?). ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3) How many physicians have been involved in the treatment of your pain? (Please circle)
0-3
4) How many emergency room visits have you had in the last year for pain? (Please circle)
5) Circle all the things that make your pain worse:

6) Circle all the things that make your pain better:
7) On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the most. 8) I have some form of pain now that requires medication each and every day Yes No 9) Did you take pain medications in the last 7 days? Yes No Name: _____________________ DOB: _____________________ 10) Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, toothaches). Have you had pain other than these everyday kinds of pain during the last week? Yes No If YES, what kind? 11) Please rate your pain by circling the one number that best describes your pain at its worst in the last week.
12) Please rate your pain by circling the one number that best describes your pain at its least in the last week.
13) Please rate your pain by circling the one number that best describes your pain on the average.
14) Please rate your pain by circling the one number that tells how much pain you have right now.
15) What kinds of things make your pain feel better (for example, heat, medicine, rest)?
16) What kinds of things make your pain worse (for example, walking, standing, and lifting)?
17) In the last week, how much relief have pain treatments or medications provided? Please circle the one percentage that
most shows how much relief you have received. 18) If you take pain medication, how many hours does it take before the pain returns? Circle appropriate response
19) I believe my pain is due to: a) The effects of treatment (for example, medication, surgery, radiation, prosthetic device) b) My primary disease (meaning the disease currently being treated and evaluated) c) A medical condition unrelated to my primary disease (for example, arthritis) 20) For each of the following words, circle Yes or No if that adjective applies to your pain.
Name: _____________________ DOB: _____________________ 21) Circle the one number that describes how, during the past week, pain has interfered with your:
d) Normal Work (includes both work outside the home and housework) 22) I prefer to take pain medicine: (circle appropriate response)
23) I take my pain medicine (in a 24 hour period): 24) Do you feel you need a stronger type of pain medication? 25) Do you feel you need to take more of the pain medication than your doctor has prescribed? 26) Do you feel you need to receive further information about your pain medication? Name: _____________________ DOB: _____________________ 27) Other methods I have used to relieve my pain include: (Please check all that apply) 28) Check the nerve blocks, injections that you have had to relieve your pain?
Medical History: (including high blood pressure, diabetes, cancer, seizure disorder, stroke, etc)

Please List: ________________________________________________________________________________________ ___________________________________________________________________________________________ Surgeries:
Have you had surgery in the past? YES NO If yes, please list by date____________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Family’s Medical History
Please list any major illnesses in your family. Including cancer, stroke, high blood pressure, diabetes, chronic pain, and others.
___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Medication Allergies
_____________________________________ ___________________________________________________ _____________________________________ ___________________________________________________ Are you allergic to iodine or contrast dye (for IVP, myelogram, etc.)? YES
If allergic, what happens? ______________________________________________________________________
Past Pain Medications:
Have you ever taken any of the following pain-related medications? If so, please check and note any
reason for discontinuing.
Medication
Last dose
Stopped due to:
Didn’t Stopped
Work Working
ACETAMINOPHEN (TYLENOL) __________________ ________________________________________  IBUPROFEN (MOTRIN, ADVIL) __________________ ________________________________________  ________________________________________  ________________________________________ ________________________________________  ________________________________________  ________________________________________ ________________________________________ ________________________________________  ________________________________________ ________________________________________  ________________________________________  ________________________________________  ________________________________________ ________________________________________  ________________________________________  ________________________________________ ________________________________________ ________________________________________  NORTRIPTYLINE (PAMELOR) __________________ ________________________________________  ________________________________________ ________________________________________  ________________________________________ ________________________________________  ________________________________________ ________________________________________  ________________________________________  PENTAZOCINE HCI (TALWIN) __________________ ________________________________________ PROPOXYPHENE (DARVOCET) __________________ ________________________________________ ________________________________________ ________________________________________  ________________________________________ ________________________________________ ________________________________________ _______________________________________ ________________________________________ _______________________________________  ________________________________________ _______________________________________  ________________________________________
Review of Systems
:
Please review the list below. If you have currently, or have had a problem in any of these areas, please circle "yes" and explain in the space below. If not, please circle "no".
General/ENT
______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Lungs and Chest
______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Heart and Blood Vessels
______________________________________________________________ YES ______________________________________________________________ YES ______________________________________________________________ YES ______________________________________________________________ YES ______________________________________________________________ YES ______________________________________________________________ YES ______________________________________________________________ YES ______________________________________________________________ YES ______________________________________________________________ Urinary/Genital
______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ YES ______________________________________________________________ ______________________________________________________________ Bones/Joints
______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Nerves/Brain
YES ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ YES ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ YES ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Stomach/Esophagus/Intestines
______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ YES ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Psychology/Psychiatry
______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ YES ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Endocrine
YES ______________________________________________________________ ______________________________________________________________ YES ______________________________________________________________ Name: _____________________ DOB: _____________________ YES ______________________________________________________________ YES ______________________________________________________________ Abnormal Vaginal Bleeding, Discharge, or Pain YES ______________________________________________________________ YES ______________________________________________________________ YES ______________________________________________________________ If yes, what do you do? ______________________________________ How many hours per day___________________ If no, how long have you been out of work? ___________ What was your occupation? ____________________________ If you do not work, how do you spend your day? __________________________________________________________ Yes No (explain)___________________________________________ Are you involved with Worker’s Compensation? Is there any litigation pending against an employer or individual involved in an accident or injury? Are you applying for disability or worker’s compensation? If so, which one? ____________________________________ HOUSEHOLD:
What are your hobbies?_______________________________________________________________________________ Single Married Separated Divorce Widowed If you have children, how many and how old?_____________________________________________________________
DAILY ACTIVITIES:

What exercises do you participate in? ___________________________________________________________________
Circle the number between 0 and 10 which represents your activity level. inactive )
0 1 2 3 4 5 6 7 8 9 10
(Very active)
SPIRITUALITY:
Do you have a religious affiliation? YES ____________________ Circle the number between 0 and 10 which represents your involvement in religious activities (i.e. church, synagogue, mosque) Name: _____________________ DOB: _____________________ EDUCATION:
Have you completed? (circle)
Circle the number between 0 and 10 which represents your involvement in social activities Is this a change since the onset of your pain? If yes, how many packs per day? ___________ How many years? __________________ About how often? __________________________________________________ Was there ever a time in your life when you may have had an alcohol problem? YES Did you or do you use street drugs? If yes, which ones _______________________________________________ NO Have you ever been addicted to prescription drugs Does anybody in your family have a history of drug misuse/abuse/addiction? Have you ever been in a treatment program for alcohol or drug abuse?
If Yes, please explain________________________________________________________________________________ Current Opioid Therapy, if applicable (for example, percocet, oxycontin, duragesic patch):
What percent relief do your opioids (narcotics) provide? ___________________________________% Do you you have any side effects from your opioids? (circle those that apply) no side effects, constipation, itching, dry mouth, nausea, erectile problems, menstrual change, vomiting, dizziness, sleepiness, lightheadedness, problems urinating, appetite change, tooth Are you any more functional from using opioids? (circle) No Yes If so, how? ___________________________________________________________________________________________ Are your opioids kept in a secure place? (circle) No Yes Where?______________________________________ Do you feel that your mood has improved from opioid therapy? (circle) No Yes If so, how? ________________________________________________________________________________________________ Has your quality of life improved? (circle) No Yes If so, how?____________________________________________ Name of pharmacy listed on opioid bottle? _____________________________________________________________ EXPECTATIONS:
What are you hoping to gain from your visit with Severn Anesthesia Advanced Pain Medicine? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Circle the percentage of pain relief you would feel would make your treatment worthwhile. PLEASE NOW FILL OUT THE ENCLOSED “CURRENT MEDICATION LIST”. LIST ALL MEDICATIONS YOU ARE
CURRENTLY TAKING (PRESCRIPTION, OVER THE COUNTER AND HERBAL).
THANK YOU FOR COMPLETING THIS FORM.

Source: http://www.severnanesthesiaadvancedpainmedicine.com/binary/org/SJM_PSP_335//severn%20new%20patient%20intake%20form.pdf

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