Patient Name:
Date of Appointment:
Age:
Weight:
Height:
Referring Physician:
Family Physician:

Medication	Dosage	Frequency

Do you have any allergies: (Please list the allergy and the reaction):
Please list the allergy and the reaction

 

Where is your pain located: (Select all that apply)

Entire body	Head	Face
Headache	Neck	Chest
RUQ/abdomen	RLQ/abdomen	LUQ/abdomen
LLQ/abdomen	Left groin	Right groin
Left shoulder	Right Shoulder	Right arm
Left arm	Upper back	Mid-back
Lower back	Sacral	Left buttock
Right buttock	Left leg	Right leg

Does your pain radiate anywhere? If so, where?:

When did the pain/injury begin:

Work Comp Injury:	Motor Vehicle Accident:	Litigation
Yes No	Yes No	Yes No

Description of pain: (Select all that apply)

Aching	Burning	Constant	Cramping
Dull	Gnawing	Heavy	Improving
Intermittent	Sharp	Shooting	Soreness
Splitting	Stabbing	Stable	Stiffness
Tender	Throbbing	Worsening

What makes your pain worse: (Select all that apply)

Bending forward	Bending Backward	Bending to the side
Coughing/Sneezing	Damp weather	Driving
Exercising	Going up/down stairs	Heat
Housework	Lifting	Lying down
Medications	Neck rotation/movement	Nerve Block Injections
Nothing	Overhead activity	Physical Therapy
Physical Activity	Resting	Sexual Activity
Sitting	Standing	Walking
Yardwork	Getting up from a sitting position	Touch/clothing

What makes your pain better: (Select all that apply)

Bending forward	Bending Backward	Bending to the side
Coughing/Sneezing	Damp weather	Driving
Exercising	Going up/down stairs	Heat
Housework	Lifting	Lying down
Medications	Neck rotation/movement	Nerve Block Injections
Nothing	Overhead activity	Physical Therapy
Physical Activity	Resting	Sexual Activity
Sitting	Standing	TENS Unit
Biofreeze gel	Frequent position changes	Hot tub
Ice Massage	Yardwork	Getting up from a sitting position
Touch/clothing

Do you have the following: (Select all that apply)

Numbness	Tingling
Pins and needles	Weakness
Coldness	Swelling
Increased hair growth	Decreased hair growth
Shiny, thin skin	Problems with bowel related to pain
Problems with bladder related to pain	Muscle spasms in the neck
Muscle spasms in the lower back	Fatigue
Difficulty Sleeping

When your pain is at its worst how do you rate it on scale of 0 (no pain) to 10 (worst pain you can imagine): 0 (no pain) 1 2 3 4 5 6 7 8 9 10 (worst possible)

When your pain is at its least how do you rate it: 0 (no pain) 1 2 3 4 5 6 7 8 9 10 (worst possible)

What is your current pain level: 0 (no pain) 1 2 3 4 5 6 7 8 9 10 (worst possible)

Which statement best describes your pain: (Select One)

Always present and always has the same intensity

Always present and the intensity varies

Usually present but have short periods without pain

Often present but have pain free periods

Often present but am pain free for most of the day

Occasionally present but have pain one to several times a day lasts few minutes to 1 hour

Rarely present but have pain every few days or weeks

What time of day is your pain the worst: (Select One)

In the morning on arising

Later in the morning

In the afternoon

At bedtime

At night (usually during sleeping hours)

In the evening

The pain varies, but is not worse at any particular time

The pain is always at its worst

Since your pain began has it: Increased Decreased Stayed the same

Have you been hospitalized for your pain? If so, what hospital and when?

Approximately how many Emergency Room visits have you had in the last year for your pain? 0 1-5 6-10 11-20 21-30

When coping with your pain are you feeling:

Depressed

Frustrated

Angry

Hopeless

Have you ever been to another pain clinic? If so, where and when:

Previous Treatment: (Select all that apply and indicate if it helped)

Therapy - Did it help? (Yes or No)

Aquatic Therapy	Yes No
Biofeedback	Yes No
TENS Unit	Yes No
Acupuncture	Yes No
Chiropractor	Yes No
Myofascial Release	Yes No
Traction	Yes No
Psychiatric Therapy	Yes No
Occupational Therapy	Yes No
Physical Therapy	Yes No
Trigger Point Therapy	Yes No

Previous Medications: (Select all that apply and indicate if it helped)

Type of Medication - Did it help? (Yes or No)

Opioids (Lortab, Hydrocodone, Darvocet, etc.)	Yes No
Antidepressants (Cymbalta, Effexor, etc.)	Yes No
NSAIDS (Ibuprofen, Aleve, Celebrex, etc.)	Yes No
Anti-convulsant (Topamax, Lyrica, Neurontin,etc)	Yes No
Muscle Relaxers (Flexeril, Zanaflex, etc.)	Yes No
Oral Steroids (Prednisone)	Yes No

Have you ever had a nerve block injection? If so, what type and how many:

Does pain keep you from taking part in social or recreational activities? If so what can’t you do that you would like to do?:

How many hours of sleep do you get in a 24 hour period?: <1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

What are your expectations for today’s visit?

Surgeries:

Date	Surgical Procedure	Surgeon’s Name

Do you have any illnesses or diagnoses, such as high blood pressure, high cholesterol, diabetes, anxiety, depression, etc? If so,what?:

Is your family history significant for anything (i.e. High blood pressure, high cholesterol, heart disease, cancer, etc.)?

Marital Status: Single Married Widowed Divorced

# of Children: 1 2 3 4 5 6 7 8 9

Do you smoke? If so, how many packs per day and for how many years? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

Do you drink alcohol? If so, how much and how often?:

Are you currently employed: Yes No

Place of Employment:

Position/Type of Work:

Retired: Yes No Disabled

Last day of Employment:

Personal or family history of drug or alcohol abuse:

Oswestry Questionnaire:

One of the goals of chronic pain management is to increase our patients’ ability to participate in activities of everyday life. Periodically, we will ask you to fill out questionnaires to help us assess your condition in this regard. Please fill out the following information as follows: (Select only ONE answer per section)

Pain Intensity:

I have no pain at the moment

The pain is very mild at the moment

The pain is moderate at the moment

The pain is fairly severe at the moment

The pain is very severe at the moment

Personal Care:

I can look after myself normally without causing extra pain

I can look after myself normally but it is very painful

It is painful to look after myself and I am slow and careful

I need some help but manage most of my personal care

I need some help every day in most aspects of my self care

Lifting:

I can lift heavy weights without extra pain

I can lift heavy weights but it gives extra pain

Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned, e.g. on the table

Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned

I can only lift very light weights

I can not lift anything at all

Walking:

Pain does not prevent me from walking any distance

Pain prevents me from walking more than one mile

Pain prevents me from walking more than ½ mile

Pain prevents me from walking more than 100 yards

I can only walk using a cane or crutches

I am in bed most of the time and have to crawl to the toilet

Sitting:

I can sit in any chair as long as I like

I can sit in my favorite chair as long as I like

Pain prevents me from sitting for more than one hour

Pain prevents me from sitting for more than ½ hour

Pain prevents me from sitting for more than 10 minutes

Pain prevents me from sitting at all

Standing:

I can stand as long as I want without extra pain

I can stand as long as I want but it gives me extra pain

Pain prevents me from standing for more than 1 hour

Pain prevents me from standing for more than ½ hour

Pain prevents me from standing for more than 10 minutes

Pain prevents me from standing at all

Sleeping:

My sleep is never disturbed by pain

My sleep is occasionally disturbed by pain

Because of pain I have less than 6 hours of sleep

Because of pain I have less than 4 hours of sleep

Because of pain I have less than 2 hours of sleep

Pain prevents me from sleeping at all

Sex Life:

My sex life is normal and causes no extra pain

My sex life is normal but causes some extra pain

My sex life is normal but is very painful

My sex life is severely restricted by pain

My sex life is nearly absent because of pain

Pain prevents any sex life at all

Social Life:

My social life is normal and causes me no extra pain

My social life is normal but increases my degree of pain

Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. sports, etc.

Pain has restricted my social life and I do not go out as often

Pain has restricted my social life to home

I have no social life because of pain

Traveling:

I can travel anywhere without pain

I can travel anywhere but it gives extra pain

Pain is bad but I can manage journeys over 2 hours

Pain restricts me to journeys of less than one hour

Pain restricts me to journeys of less than ½ hour

Pain prevents me from traveling except to receive treatment

Review of Systems:

General:

Fever	Chills	Sweats
Decreased appetite	Fatigue

Eyes:

Blurring	Double Vision	Irritation
Discharge	Vision Loss	Eye Pain
Light sensitivity

Ear/Nose/Throat:

Earache	Ear discharge	Ringing in ears
Hearing Loss	Congestion	Nose bleeds
Sore throat	Hoarseness	Difficulty swallowing

Cardiovascular:

Chest pains	Palpitations	Fainting
Difficulty breathing with activity	Breathlessness	Difficulty breathing lying flat
Swelling in feet/ankles/hands

Respiratory:

Cough	Difficulty breathing	Excessive sputum
Coughing up blood	Wheezing

Gastrointestinal:

Nausea	Vomiting	Diarrhea
Constipation	Change of bowel habits	Abdominal pain
Black/tarry stools/blood in stools	Jaundice

Genitourinary:

Discharge	Incontinence	Difficult/Painful urination
Blood in urine	Urinary frequency	Urinary urgency
Night urination	Absence of periods	Excessive period
Abnormal vaginal bleeding	Pelvic pain	Genital sores
Impotence	Decreased libido

Musculoskeletal:

Back pain	Joint pain	Joint swelling
Muscle cramps	Muscle weakness	Stiffness
Arthritis

Skin:

Rash	Itching	Dryness
Suspicious lesions

Neurologic:

Transient paralysis	Weakness	Pins and needles feeling
Seizures	Tremors	Dizziness

Psychiatric:

Depression	Anxiety	Memory loss
Mental disturbance	Suicidal thoughts	Hallucinations
Paranoia

Endocrine:

Cold intolerance	Heat intolerance	Intense thirst
Excessive eating	Excessive urination	Weight change

Heme/Lymphatic

Abnormal bruising

Bleeding

Enlarged lymph nodes

Allergic/Immunologic:

Hives	Hay fever	Persistent infections
HIV exposure

Ambulation Aids:

Cane

Walker

Wheelchair

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