Health History Form PAIN TREATMENT HISTORY
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- Noah Fitzgerald
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1 Name: Health History Form Date of Birth: / / Reason for today s visit: Please mark the types of healthcare providers you have seen for this condition previously: Primary Care Provider Orthopedic Surgeon Rheumatologist (arthritis) Neurologist Neurosurgeon Physiatrist Physical/Occupational Therapy Chiropractor Acupuncture Other Pain Management specialist In the space below please name the providers marked above and the approximate dates you were treated: Please mark any exams you have had for this condition previously: X-Ray Ultrasound CT-Scan MRI PET Scan Body Scan EMG Sleep Study Pulmonary Function Studies EKG In the space below please indicate which area of the body correlated with the exam and approximate date of the exam: Please list other treatments/procedures you have used to treat this condition: PAIN TREATMENT HISTORY PAIN: Location 1 Location 2 Location 3 Where is your pain? When did it start? How did it begin? (Suddenly, gradually, injury, at work, fall, etc.) What does it feel like? (Burning, aching, sharp, dull, shooting, etc.) Please draw on the diagram where your pain is located. (Circle one) Pain level now? (0=no pain, 10= worst imaginable pain) Average pain level over the last month Lowest that it has been in the last month or two Highest that it has been in the last month or two Page 1 of 5
2 PREVIOUSLY TRIALED AND FAILED MEDICATION PROFILE Please mark if you have taken any of the following medications for any of these conditions. In the space provided please include to the best of your memory the start and stop dates and reasons for stopping. This information is helpful in the event we need to work with your insurance company to request prior authorization for your prescribed medications. (If you choose not to complete this, it can delay completing or getting any prior authorizations for your medication). NSAID s: ibuprofen/advil/motrin celecoxib/celebrex meloxicam/mobic naproxen/aleve/naprosyn nabumetone/relafen prednisone diclofenac/voltaren Pennsaid (diclofenac topical) Flector (diclofenac patch) Voltaren (diclofenac)gel Short Acting: ultram/tramadol morphine oxycodone hydromorphone/dilaudid Vicodin/hydrocodone w acetaminophen Percocet/oxycodone w acetaminophen demerol/meperidine buprenorphine/subutex Long Acting: fentanyl/duragesic patch morphine/kadian morphine/avinza morphine/oramorph tramadol/nucynta ER methadone/dolophine hydromorphone/exalgo buprenorphine/butrans codeine/oxycontin oxymorphone/opana Page 2 of 5
3 Muscle Relaxers: cyclobenzaprine/flexeril metazalone/skelaxin methocarbamol/robaxin carisoprodol/soma tizanidine/zanaflex baclofen/lioresal Depression/Pain/Sleep: citalopram/celexa escitalopram/lexapro fluoxetine/prozac fluvoxamine/luvox paroxetine/paxil sertraline/zoloft buproprion/wellbutrin venlafaxine/effexor trazodone/desyrel zolpidem/ambien triazolam/halcion temazepam/restoril estazolam/prosom eszopiclone/lunesta ramelteon/rozerem Central Nervous System/Neuropathic Pain/Migraine: pramipexole/mirapex ropinorole/requip memantine/namenda gabapentin/neurontin gabapentin/gralise carbamazepine/tegretol amitriptyline/elavil topiramate/topamax lomatrigine/lamictal valproic acid/divalproex/depakote levetiracetam/keppra prebagalin/lyrica rizatriptan/ Maxalt sumatriptan/imitrex eletriptan/relpax zolmitriptan/zomig sumatriptan/sumavel Treximet (sumatriptan/naproxen) Page 3 of 5
4 (Please circle all that apply) What aggravates your pain? What relieves your pain? heat cold activity driving lying down sitting standing walking bending lifting weather prolonged positions stress heat cold activity rest lying down sitting standing walking massage changing positions stretching medication Associated signs problems sleeping depression anxiety sexual issues & symptoms: decreased range of motion difficulty urinating saddle anesthesia bowel or bladder dysfunction numbness or tingling Pain is worse in: Pain is: morning afternoon evening night continuous intermittent SOCIAL HISTORY (Please circle all applicable responses) Marital Status Single Significant Other Married Divorced Widowed Living Situation Alone Spouse/Significant other Children/Family Other Females- Are you pregnant? Hysterectomy Menopause Tubal ligation Do you have children? If yes, how many? Education (highest level) Some college Associates Bachelors GED Masters PhD Are you working? If yes, occupation? Are you disabled? If yes, reason? Any legal actions related to a pain condition? Explain: If applicable, amount? Tobacco Use? If no, have you ever? Cigarettes / Cigars / Chew Cigarettes / Cigars / Chew Per day: Per day: Do you drink alcohol? Beer / Wine / Liquor Per day: Do you drink caffeine? Coffee / Tea / Soda / Energy Drink Per day: Any present illicit drug use? Marijuana / Cocaine / Heroin / Illicit Rx. / Other Any past illicit drug use? Marijuana / Cocaine / Heroin / Illicit Rx. / Other Do you exercise? Type? Per week: Do you wear your seatbelt? If yes, percent of time: Do you have Advanced Directives in Living Will Durable Power of Attorney place? Health Care Proxy Advanced Directives SURGICAL HISTORY (Please list all past surgeries/operations): Type of Operation Date Type of Operation Date Page 4 of 5
5 FAMILY HISTORY (Please tell us about the health of your immediate family) Father Mother Siblings Children Other Age at Death Cause of Death Heart Disease/ Stroke High Blood Pressure Diabetes Chronic Pain Cancer (type) Other: MEDICAL HISTORY (Please check any of the following that you have or have had in the past) Acid Reflux/GERD ADHD Alcoholism Anemia Anxiety Arthritis Asthma Bleeding Disorders Bowel Problems Cancer Chronic Cough Chronic Pain COPD/Emphysema Dementia Depression Diabetes Eating Disorder Glaucoma/Cataracts Headaches Hearing Loss Heart Disease Heart Palpitations Hepatitis High Blood Pressure High Cholesterol HIV/AIDS Immune disorders Kidney Disease Liver Disease Osteoporosis Seizure Disorder Sexually Transmitted Disease Stroke Thyroid Disease Tuberculosis Other: MEDICAL AND MENTAL HEALTH HISTORY (Include all injuries or hospitalizations): Name of Facility Reason Date CURRENT MEDICATIONS Name of Medication Strength (ex. 500 mg) Dosing Instructions (ex. Twice a day) ALLERGY HISTORY No Known Allergies Medication Allergies Environmental/Seasonal Allergies Latex Allergies Allergen (ex. Food, Dust, Animals, Pollen, Medication) Reaction (ex. Rash, nausea, respiratory, shock, etc.) Page 5 of 5 FO-EN-102-PCC-V Health History
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