PAIN SOLUTIONS NEW PATIENT QUESTIONNAIRE Patient Name: __________________ DATE______________________ Primary Doctor: _____________________________ Referring Doctor: _____________________ Please show the location of your pain by drawing on the figures below:
Pain History (PLEASE FILL IN THE BUBBLES)
1. WHERE IS YOUR PAIN LOCATED?
2. WHERE DOES THE PAIN RADIATE? 3. THE PAIN FIRST STARTED: Was there an accident or injury that caused the pain?
O YES _____________________________________________________________________
4. HOW WOULD YOU DESCRIBE YOUR PAIN? (mark all that apply)
5. RATE YOUR PAIN AT IT’S WORST IN THE LAST 24 HOURS?
6. RATE YOUR PAIN AT IT’S BEST IN THE LAST 24 HOURS?
7. HOW SEVERE IS YOUR PAIN ON AVERAGE?
8. HOW MUCH DOES THE PAIN INTERFERE WITH YOUR ACTIVITIES?
9. HOW MUCH DOES THE PAIN INTERFERE WITH YOUR SLEEP?
10. THE PAIN IS:
11. WHAT MAKES THE PAIN WORSE?
12. WHAT MAKES THE PAIN BETTER?
13. IN ADDITION TO THE PAIN, DO YOU HAVE?
14. IS YOUR PAIN:
15. WHAT TESTS HAVE YOU HAD FOR YOUR PAIN? (Please list date of last exam)
O MRI Scan_____________ O CT Scan____________
16. WHAT MEDICATIONS HAVE YOU TRIED FOR YOUR PAIN? (Check ALL that apply) Anti-Inflammatory: O Ibuprofen (Advil, Motrin) Narcotic: Antidepressants
O Fluoxetine (Prozac) O Escitalopram (Lexapro)
O Venflaxine (Effexor) O Sertraline (Zoloft)
O Nortriptyline (Pamelor) O Desipramine (Norpramine)
O Citalopram (Celexa) O Paroxetine (Paxil)
Anti-Seizure
O Pregabalin (Lyrica) O Zonisamide (Zonegram)
O Lamotrigine (Lamictal) O Oxycarbazepine (Trileptal)
Muscle Relaxants/
O Tizanidine (Zanaflex) O Metaxolone (Skelaxin)
Anti-Anxiety
O Cyclobenzaprine (Flexeril) O Methocarbamol (Robaxin)
Sleeping Aids Other Pain Meds
17. WHAT TREATMENTS HAVE YOU HAD FOR YOUR PAIN?
O Other __________________________________________________
Past Medical History (Please Fill in “yes” or “no” to all questions) CARDIOVASCULAR GASTOINTESTINAL RESPIRATORY NEUROLOGY
Social History
Drug(s) Used ____________________________________
OTHER SYMPTOMS (Please indicate other symptoms you may have) CONSTITUTIONAL NEUROLOGY RESPIRATORY MUSCULOSKELETAL CARDIOVASCULAR HEMATOLOGY CURRENT MEDICATIONS (Include dosage and # tablets per day)
Have you had any surgeries? _____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are you taking any of the following blood thinners? ___ Coumadin ___ Plavix Do you have any allergies to medications? ___ Latex ___ Iodine __Other Medications? ___________________
What are your goals for your pain treatment? __________________________________________________________________________________ __________________________________________________________________________________ Are there any specific treatments that you would like for your pain? Medications: __________________________________________________ Physical Therapy: ______________________________________________ Exercise: ______________________________________________________ Psychologist referral: ___________________________________________ Surgery referral ________________________________________________ Injections: ______________________________________________________ Other pain therapies: (Please circle) Do you have a driver with you today? __ yes __ no THIS IS THE END OF THE QUESTIONNAIRE. THANK YOU!
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PAIN SOLUTIONS