Patient Information Form Pain Management Center at Phoebe
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- Augustine Welch
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1 Patient Information Form Pain Management Center at Phoebe Please complete the following form, so that we may facilitate your visit Occupation: or (circle) Retired, Disabled Homemaker, Full time student Where is your pain? Date began: What caused this pain to begin? Are you seeking Disability? Do you have legal representation, a lawyer to help you? Describe your pain: (circle) burning, shooting, aching, throbbing, tingling and or numbness. Other: Pain is: (circle) Mild, Moderate, Moderate to Severe, Severe Pain is: (circle) Constant-all the time, Episodic-comes and goes If tingling or numbness where? What are your goals of pain management? (Circle) reduce or control pain, Increase activity, increase sleep, Return to work, Increase social activities Other: What makes your pain worse? What helps your pain makes it better? Medical Doctor Name/Location: Height :( how tall you are?) Weight:
2 ALLERGIES (WHAT TYPE OF ALLERGY) ALLERGIES (allergic too) ALLERGIC REATION (rash, nausea etc) PREVIOUS SURGERIES (ALL SURGERIES) Year Type of Surgery Year Type of Surgery CURRENT MEDICATIONS Start Start
3 PREVIOUS MEDICATIONS (TRIED FOR THIS PAIN PROBLEM) Stop Stop Have you tried the following treatment for your Pain problem? DID IT HELP?? TREATMENT TRIED *Chiropractic care *Physical Therapy *TENS unit (electrical Stim device) *Acupuncture *Massage Therapy *Water (Pool) Therapy *Biofeedback *Injections/ Nerve Blocks/ Epidurals *Radiofrequency of nerves *Dorsal Column Stimulator trial Date Tried YES NO COMMENTS PREVIOUS Diagnostic Studies Date Type of Study Date Type of Study (may list) X-rays of MRI of CT Scan of Myelogram of Dexa Scan (Bone Density study) Nuclear Bone Scan Nerve Conduction Study of Electromyogram (EMG) of Discogram of Spinal Tap
4 PLEASE Check all that apply History of: Diarrhea Headaches Cluster headaches Migraines Stroke Head Injury / Coma Peripheral Neuropathy Shingles Seizures Depression Anxiety Suicide thoughts Pneumonia Bronchitis Asthma Emphysema/COPD Tuberculosis High blood pressure Congestive Heart Failure Angina (chest Pain) Heart Attack Coronary Artery disease Angioplasty/ Diet please check the following REGULAR DIET DIABETIC DIET LOW Sodium/Low Fat diet GOOD Appetite FAIR Appetite POOR Appetite Hepatitis Pancreatitis Abdominal (Stomach) Pain Ulcers Stomach or bowel bleeding Acid Reflux Hiatal hernia (stomach) Irritable Bowel Syndrome (IBS) Hemorrhoids Diverticulosis Colon Polyps Kidney or Bladder infections Urinary Frequency Blood in Urine Kidney Stones Prostatitis (BPH) enlarged prostate Prostate Cancer Night time Urination Kidney Failure/ Dialysis Skin Cancers Psoriasis or eczema Rash Bruises currently on arms or legs Current wound/burn/laceration Osteoarthritis Rheumatoid Arthritis Osteoporosis Fibromyalgia Gout Unsteady walk, history of falls Use a cane, walker or wheelchair Thyroid problems Diabetes Long term steroid therapy Anemia Free bleeder (bleed easily) Blood Clots (legs or lungs) Sickle Cell Anemia Bruise easily Previous blood transfusion Hearing impaired Dentures, caps, crowns, missing or bad teeth? (may circle) Last Menstrual period Constipation Last Mammogram
5 Substance use: If you would rather, you may wait and discuss these issues with the Nurse. Do you use tobacco? Yes No ** Smoke ** Dip ** Chew How much? ½ PPD 1 PPD 2PPD Other: How many years? Do you use Alcohol? Yes No Amount/frequency: History of Alcohol abuse? Yes No Quit/When: Do you use Street Drugs? Yes No Type/frequency: History of Drug abuse? Yes No Type/last use: Comments or additional information you would like to share
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