INITIAL PATIENT QUESTIONNAIRE-

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Eunice Barber
8 years ago
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1 Date: Patient Address: Home Phone: Work Phone: Age: Height: cm/inches Weight: kg/lbs Male Female Referring Physician s Name: Physician Phone: Physician Address: Type of Practice (Internist, Surgeon, etc.): CHIEF COMPLAINT: Do you have- Neck pain Yes No Upper back pain Yes No Shoulder pain Yes No Low back pain Yes No Arm pain Yes No Hip/Leg pain Yes No Any other complaints: If more than one area, which is worse? How long have you had this problem? Did your symptoms follow an injury? If yes, please indicate: Work Auto accident Other Describe: Circle your least and greatest pain levels over the past two weeks: (None) (Severe) Describe your pain (check all that apply): Constant Deep Dull Sharp Intermittent Throbbing Stiffness Aching Shooting Cramping Burning Stabbing Is your pain worse (check one) At night In the morning End of the shift/day No difference between day and night On a wet/cloudy day UWH# DT (Rev. 10/23/12) Scan to Questionnaire-Health Page 1 of 6

which is worse? How long have you had this problem? Did your symptoms follow an injury?

2 Indicate which of the following activities increase ( I ) or decrease (D) your pain When I first get out of bed Standing Getting up Walking Sitting Bending back Lying on my back/side Lying on stomach Leaning forwards Coughing/Sneezing Lifting/bending forwards Twisting Straining Reaching over Look up/turn head sideways Washing/combing hair Climbing stairs/walking up ramp Going down stairs/ramp Long car rides Other Have you had neck/back symptoms before? Yes No Have you had previous back or neck surgery? Yes No If yes, describe: Have you had prior episodes of back symptoms for which you received Worker s Compensation? Yes No Is the purpose of this exam to determine disability status for the government or an insurance agency? Yes No Are you currently receiving any type of financial compensation for your back problem? Yes No Do you have an attorney for your back problem? Yes No Mark in the areas of your body where you now feel your typical pain. Include all affected areas. Use the appropriate symbols indicated below: Front Back PAIN = XXXXXXXXX NUMBNESS = OOOOOO Right Left Left Right Pain Diagram UWH# DT (Rev. 10/23/12) Scan to Questionnaire-Health Page 2 of 6

Long car rides Other Have you had neck/back symptoms before? Yes No Have you had previous back or neck surgery?

3 Date Location MRI: CT Scan: Myelogram: Bone Scan: EMG: Xrays: PREVIOUS TREATMENT: Put a check next to each type of treatment you have had for your back/neck in the past. Then check the column that best describes the effect of the treatment. Treatment ( ) if you have Did it make things ( ) had this Better Worse No change Hot packs/ice Ultrasound Massage TENS/Electrical Stimulation Yoga/Tai-Chi Exercises Traction Bed Rest Pool Therapy Biofeedback Injections Braces/Splints Medication Acupuncture Chiropractic Adjustments MEDICAL HISTORY: Have you ever had: AIDS or HIV testing Phlebitis or blood clots Kidney Stones Asthma/Breathing problems Stroke Arthritis Cancer Thyroid trouble Seizures Radiation/Chemotherapy Kidney Infections Ulcer Heart Attack Migraine or other severe head pain Tuberculosis High Blood Pressure Diabetes Hepatitis Chronic Fatigue Syndrome Fibromyalgia Other: UWH# DT (Rev. 10/23/12) Scan to Questionnaire-Health Page 3 of 6

Treatment ( ) if you have Did it make things ( ) had this Better Worse No change Hot packs/ice Ultrasound Massage TENS/Electrical Stimulation Yoga/Tai-Chi Exercises Traction Bed Rest Pool Therapy

4 REVIEW OF SYSTEMS: ( ) all that apply. Constitutional Allergy/Immune Neurological Musculoskeletal Fever Drug allergy Paralysis Joint stiffness/swelling Chills Seasonal allergy Tremors Muscle pain/swelling Night sweats Food Allergy Spasticity Fatigue Weight loss Iodine allergy Seizures Fractures Loss of appetite Transplant Muscle atrophy Hemo-lymphatic CV/Respiratory Gastrointestinal Endocrine Anemia Shortness of breath Difficulty swallowing Obesity Excessive bleeding Wheezing Heartburn Thyroid Disorder Easy bruising Cough Nausea/vomiting Diabetes Lymphoma Coughing up blood Constipation Menopause Leukemia Chest Pains Diarrhea Menstrual irregularities Cancer Palpitations Blood in stools Pelvic pain Lymph node swelling Leg swelling Stomach pain Addison s disease HENT Skin/Integumentary Genitourinary Psychiatric Loss of vision Rash Pain urinating Poor sleep Eye Redness Ulcer Incontinence Depression Headaches Eczema Blood in urine Anxiety Dizziness Hives Dribbling Stress at work/home Glaucoma Sexual Difficulties Panic Spells Pregnant ; LMP PAST SURGICAL HISTORY: Year Operation Place Hospitalized If you had previous back surgery; What were your symptoms before the surgery? (indicate R for right side, L for left side, B for both sides and circle all that applies) Neck Pain Shoulder pain/numbness/weakness Arm pain/numbness/weakness Wrist/hand pain/numbness Back Pain Hip/buttock/thigh pain/numbness/weakness Leg pain/numbness/weakness Ankle/foot pain/numbness/weakness Urinary complaints Bowel Complaints Impotence Walking/gait disturbances Balance/falls/clumsiness UWH# DT (Rev. 10/23/12) Scan to Questionnaire-Health Page 4 of 6

Spasticity Fatigue Weight loss Iodine allergy Seizures Fractures Loss of appetite Transplant Muscle atrophy Hemo-lymphatic CV/Respiratory Gastrointestinal Endocrine Anemia Shortness of breath

5 Did your symptoms improve after surgery? If yes, how long afterwards? Did you get worse after surgery? If yes, explain: Were you released back to work after surgery? If so, when? ALLERGIES: Name of medicine/substance Type of reaction Date MEDICINES: List all medicines that you have taken recently. Include vitamins and non-prescription medicine FAMILY HISTORY: Spinal Problems Yes No If yes, describe: Bleeding Disorders Yes No If yes, describe: Heart Disease Yes No If yes, describe: Cancer Yes No If yes, describe: Diabetes Yes No If yes, describe: SOCIAL HISTORY: How many years of schooling? (circle one) Less than high school high school graduate technical school diploma 1-3 years of college College graduate post graduate or professional degree Marital Status: Single Married Separated Divorced Remarried Widowed How many years? Number of children? Ages: Who lives with you at home? Working status: Working Not Working Student Disabled Retired Primary Occupation: Employer: UWH# DT (Rev. 10/23/12) Scan to Questionnaire-Health Page 5 of 6

FAMILY HISTORY: Spinal Problems Yes No If yes, describe: Bleeding Disorders Yes No If yes, describe: Heart Disease Yes No If yes, describe: Cancer Yes No If yes, describe: Diabetes Yes No If yes,

6 How long have you worked at your present job? If not working, last date worked: Spouse s Occupation: Have you ever smoked? Yes No Type/Amount: Years: If quit, when? Amount of alcohol consumed in a typical week? Cups of caffeinated drinks per day? Have you used: Marijuana Cocaine Heroin Other Do you get any regular exercise? Describe: Please complete this form and bring with you to your appointment. Our clinic is located at 6630 University Ave. Completed by: Date: If not completed by patient, relationship to patient: Reviewed by: Date: Time: UWH# DT (Rev. 10/23/12) Scan to Questionnaire-Health Page 6 of 6

Have you used: Marijuana Cocaine Heroin Other Do you get any regular exercise? Describe: Please complete this form and bring with you to your appointment.

New England Pain Management Consultants At New England Baptist Hospital

New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants