George Washington University Hospital The GW Pain Center
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- Thomasina Goodman
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1 1 COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM DATE: PHYSICIAN: Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name of Family Physician: Phone: Fax: Address: City: State: Zip: A. When did your pain start? B. What caused your pain? Accident Cancer Other Disease Surgery (specify) No obvious cause C. Describe in your own words the pain problem(s) that you would like help with:
2 George Washington University Hospital D. How often does your pain occur? E. How long does your pain last? Continuous Continuous Several times a day Weeks Once a day Days Several times a week Hours Once a week Minutes Less than once a week Seconds Never None 2 F. Below is list of words that might describe your pain. Circle all that apply: Throbbing Hot-Burning Shooting Aching Stabbing Heavy Sharp Tender Cramping Splitting Gnawing Tiring-Exhausting Sickening Fearful Punishing-Cruel Other: G. Circle the number below to indicate your highest pain intensity over the past week: None Mild Moderate Severe Most H. Circle the number below to indicate your lowest pain intensity over the past week: None Mild Moderate Severe Most I. Circle the number below to indicate your usual pain intensity over the past week: None Mild Moderate Severe Most J. Circle the number below to indicate how much your pain interferred with your activities this week: None Mild Moderate Severe Completely K. What makes your pain better? Sitting Standing Walking Bending Lying Down Driving Coughing/Sneezing
3 L. What makes your pain worse? 3 Sitting Standing Walking Bending Lying Down Driving Coughing/Sneezing M. Please indicate where you have pain by marking the areas on your body. N. Have you had any of the following tests to evaluate your pain? (please provide details) X-Rays MRI CT Scan Myelogram EMG Blood Tests Bone Scan Discogram O. Do you have any of the following conditions associated with your pain? (indicate all that apply): Bowel/Bladder Incontinence Muscle Weakness Numbness/Tingling/Pins/Needles
4 4 P. Please indicate any previous treatments you have tried for your pain and whether they helped your pain: Yes No Accupuncture Chiropractor Biofeedback Traction TENS Unit Physical Therapy Massage Psychologist Psychiatrist Alternative Medicine Surgery Medications Epidurals Q. Past Medical History Yes No Yes No Arrythmia Liver Disease High Blood Pressure Hepatitis Angina/Heart Disease Kidney Disease Heart Attack Ulcers Heart Failure Acid Reflux Emphysema/Asthma Other GI Illness COPD Bleeding Disorder Stroke Taking Blood thinners Seizures Thyroid Disease Cancer HIV Arthritis Irritable Bowel Disease Diabetes Skin Condition Migraine Headaches Depression Psychiatric Illness Other: R. Past Surgical History (please indicate type of surgery, date and physician s name) Surgery Date Surgeon
5 5 S. Do you have any allergies to medications? T. Current Medications: Name Dose How Many Times a Day U. What is your mood like now? Worst Poor Fair Good Best V. Do you have problems with any of the following? (check all that apply) Yes No Yes No Sleep Concentration Mood Anxiety Depression Suicidal thoughts Self-worth Homicidal thoughts W. Family History Mother: Living/Deceased Father: Living/Deceased Siblings: Living/Deceased Siblings: Living/Deceased Cause: Cause: Cause: Cause: X. Social History Relationship Status Married Single Divorced Separted Widowed Domestic Partnership
6 6 With whom do you live? Self Spouse Children Parents Friends Other: What is your current employment status? Employed full-time Employed part-time Self-employed Retired Homemaker Unemployed due to pain Unemployed due to other reason. Are you on disability? Yes No Y. Do you have an attorney or legal action pending related to this pain or any other health problems? Yes No If so, please list attorney s name: Do you drink alcohol? Yes No If so, specify Do you smoke? Yes No If so, specify Do you currently or have you ever abused recreational drugs? Yes No If so, specify: Y. Do you experience any of the following? Review of Symptoms (please indicate all that apply): Yes No Yes No Fever Weight Loss Night Sweats Swelling Rash Cough Sputum Production Shortness of Breath Wheezing Chest Pain Chest Pain Palpitations Abdominal Pain Constipation Diarrhea Black bowel movement Blood in stool Nausea Headache Lightheadness Dizziness Vision Changes Easy Bruising Urinary Frequency Difficulty Urinating Pregnancy Bowel or Bladder Incontinence Weakness/Paralysis of the arms and legs
7 ***********PHYSICIAN ONLY************ 7 Physical BP: HR: RR: Temp: Ht: Wt: General: HEENT: NC/AT Neck: Supple Lungs: Clear CV: RR Abd: Soft, NT/ND GU: Deferred Skin: Clear Extremites: WNL Pulses: +2 Radial/DP Neuro: CN II-XII grossly intact Sensory: UE: R LT/PP LE: R LT/PP L LT/PP L LT/PP Motor: C5 C6 C7 C8 T1 RUE /5 /5 /5 /5 /5 LUE /5 /5 /5 /5 /5 L2 L3 L4 L5 S1 RLE /5 /5 /5 /5 /5 LLE /5 /5 /5 /5 /5 Gait: Musculoskeletal: Reflexes: SLR Slump Spurling FABER/Patrick Ganselen Other: Palpation: TTP MTrP:
8 ***********PHYSICIAN ONLY************ 8 RADIOGRAPHIC DATA: IMPRESSION: PLAN: SIGNATURE: DATE:
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