Questionnaire for New Patients

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Transcription:

Questionnaire for New Patients Hello and welcome to The Center for Pain Medicine at Massachusetts General Hospital. We ask that you help us by providing as much information as you can regarding your current condition and ongoing treatment as well as any prior diagnostic tests and treatments that you may have had. This questionnaire is designed to step you through all areas of your past and present medical care. Please complete as much of this forma s you are able to prior to your first visit, so that we can use this information at the time of your first visit to get a complete picture of you and your overall condition. Please do not hesitate to ask any of our staff or physicians for assistance if you have any questions or concerns. We look forward to meeting you. GENERAL INFORMATION Name: Address: Home phone: Work phone: Date of birth: / / Referring Physician: Address: Phone: Primary Care Physician (if different from referring physician): Address: Phone: Pharmacy: Phone: Address: PAGE 1 OF 7

DESCRIBE YOUR PAIN SYMPTOMS When did your pain first start? Where is your pain? What do you think is causing your pain? Did your pain begin with an injury? No/ Yes: If you were injured, did the injury occur: at work, in a motor vehicle accident, or under other circumstances? Please explain how you were injured: Please rate your pain on a scale from 0 (no pain) to 10 (the most severe pain you can imagine): How severe is you pain at its WORST? /10 How severe is your pain at its BEST? /10 What does your pain feel like? (Check all that apply) Throbbing Shooting Stabbing Burning Sharp Tingling Numb Tender Pressure Deep Aching Cramping Heaviness Other: What is the pattern of your pain? Continuous (always present) Comes and goes Gets worse as the day goes on What makes your pain worse? Sitting Bending Lifting Twisting Driving Coughing Sneezing Standing Walking Lying down PAGE 2 OF 7

Other, explain: What makes your pain better? Rest Lying down Bending Sitting Medication Ice or heat other, specify: Does your pain interfere with any of the following? (check all that apply) Sleep Daily activities Work Relationships Does your pain make you feel: (check all that apply) Depressed Angry Frustrated Helpless/hopeless Please check any previous treatments you have had for your current pain: Herbal remedies Physical or occupational therapy Work hardening TENS unit Chiropractor visits Injections Surgery Counseling Hypnosis Biofeedback Acupuncture List any tests you have had related to your current pain: X-ray CT scan MRI Myelogram Bone scan EMG Blood tests ALLERGIES AND MEDICATIONS Allegries and intolerances: (Please list all allergies or intolerances) Current pain medications: Please list all prescription and non-prescription medications you are currently taking for pain: (Please include dose and frequency) Previous pain medications. Please list all prescription and non-prescription medications you have taken in the past for pain: (Please include dose, frequency, and the reason each medication was stopped ) PAGE 3 OF 7

Other medications. Please list all prescription and non-prescription medications you are currently taking for other medical conditions: (Please include dose and frequency) Are you currently taking any blood thinning medications? No/ Yes: PAST MEDICAL PROBLEMS Have you ever had any of the following medical conditions? (Check all that apply) Diabetes Bleeding disorder Heart murmur Rheumatic fever HIV or AIDS Stroke Heart attack Heart problems Aneurysm Circulation problem High cholesterol Seizures Cancer Kidney problems High blood pressure Respiratory problems Thyroid problems Ulcers Liver problems Heartburn Pacemaker Hepatitis Asthma Sleep apnea Defibrillator Fibromyalgia Other: PAST SURGERY Please list any previous surgery you have had: (Please include the month and year each surgery was done) PAGE 4 OF 7

FAMILY HISTORY Does anyone in your family suffer from chronic illness: No/ Yes: Relationship (e.g. father, sister, etc.) Illness SOCIAL HISTORY What was the highest level of education you completed? High school College Graduate school What is you marital status? Single Married Separated Divorced Widowed How many children do you have? Do you smoke? No/ Yes: If yes, how many packs/day How many years have been smoking? Do you drink alcohol? No/ Yes: If yes, how much and often do you drink? (e.g. 2 glasses of wine/day) Do you use recreational drugs? No/ Yes: If yes, please describe Do you exercise regularly? No/ Yes: If yes, how often? WORK HISTORY Are you currently working? No/ Yes: If yes, who is your current employer: What is your occupation? Are you on disabled? No/ Yes: If yes, how long have you been disabled? What caused you to become disabled? PAGE 5 OF 7

PSYCHOSOCIAL HISTORY Have you ever been treated for emotional/behavioral disorder? No/ Yes: If yes, please describe: Have you ever been treated for depression? No/ Yes: If yes, when: Have you ever attempted suicide? No/ Yes: If yes, when: Do you currently have suicidal thoughts? No/ Yes REVIEW OF SYSTEMS Please circle any of the following problems that you are now experiencing: Constitutional: weight change weakness fatigue fever Eyes: change in your eyeglass prescription eye pain tearing double vision Ear, Nose, Throat: hearing loss nasal congestion ringing in your ears dizziness sore throat Cardiovascular: shortness of breath chest pain palpitations ankle swelling Respiratory: cough sputum coughing up of blood difficulty breathing wheezing Gastrointestinal: heartburn nausea or vomiting abdominal pain constipation diarrhea bowel incontinence bloody stool Genitourinary: pain with urination bladder incontinence urgency blood in urine Musculoskeletal: joint pain stiffness neck or backache Skin: rash lumps itching hair changes nail changes Neurological: headache weakness numbness seizures blackouts memory loss Psychological: nervousness tension depression anxiety Endocrine: heat or cold intolerance sweating thirst hunger change in urination Hematologic: bruising bleeding Is there any chance you could be pregnant? No/ Yes PAGE 6 OF 7

WHERE IS YOUR PAIN? Please shade the areas of your pain in the diagrams below. I, the undersigned, have completed this form to the best of knowledge. The information that I have provided is true and accurate to the best of my knowledge. Patient/Guardian Signature Physician Signature Date Date PAGE 7 OF 7

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