Pain Management Center of Lansing

Questionnaire

Patient's First Name

Patient's Last Name

Today's Date

Date of Birth

Sex

Female Male

Height

ft. in.

Weight

lbs.

Primary care physician

Primary care physician phone

Referring physician

Referring physician phone

Other physicians consulted

Other physicians consulted phone

When did your pain start?

How did your pain start?

Auto Accident After Surgery Fall (not at work) Work Related Other :

Describe the Problem

Briefly List

Treatments tried

Injections tried

Medications tried

Physical therapy tried

Have you had any previous...

CT scans

When
facility name

MRI

When
facility name

EMG

When
facility name

Bone Scans

When
facility name

Describe where your pain is on your body

Please indicate on a scale of 0-10 what level your pain is,
0 = no pain, 10 = unbearable pain

PRESENT PAIN

0 1 2 3 4 5 6 7 8 9 10

USUAL PAIN

0 1 2 3 4 5 6 7 8 9 10

LEAST SEVERE PAIN

0 1 2 3 4 5 6 7 8 9 10

WORST PAIN

0 1 2 3 4 5 6 7 8 9 10

In the last 2-3 weeks, how often has your pain occured?

Constant Intermittent Less than 8 hours a day 8-16 hours a day

What does your pain feel like? (check all that apply)

mild burning tingling sharp shooting dull aching other

Other, please describe:

What has been used to treat your pain? (check all that apply)

medication individual psychotherapy other Pain Center biofeedback group psychotherapy physical therapy injections relaxation training occupational therapy treatments in the emergency room(ER)

How many times have you been to the ER for pain control over the last 3 months?

other

Other, please describe:

What increases your pain? (check all that apply)

sitting going up or down stairs driving a vehicle standing bending or transferring positions sports, physical recreation, crafts, or hobbies walking employment or working self-care (bathing, dressing, toileting, etc.) lifting, carrying, housework, or yard work (laundry, meal preparation, etc.)

other

Other, please describe:

What decreases your pain? (check all that apply)

not working walking heat medications exercising sitting lying down stretching TENS physical therapy standing resting cold injections

other

Other, please describe:

Does your pain keep you from falling asleep at night?

Yes No

Does your pain awaken you at night?

Yes No

What is your goal for treatment at the Pain Center?
(For example: What are the activities you would like to do if the pain was better controlled?)

Do you have any other comments about your pain, not already noted here?

Do you have any numbness?

Yes No

Do you have any weakness?

Yes No

Do you have any changes in your bowel/bladder?

Yes No

Past and Present Medical Problems

What are your past or current medical problems? (check all that apply)

Heart Disease

Yes No

Rheumatic Fever

Yes No

High Blood Pressure

Yes No

Lung Disease

Yes No

Bronchitis or Pneumonia

Yes No

Asthma

Yes No

Liver or Gall Bladder Problem

Yes No

Hepatitis

Yes No

Peptic Ulcer Disease

Yes No

Colitis

Yes No

Pancreatitis

Yes No

Bladder or Kidney Disease

Yes No

Arthritis

Yes No

Diabetes

Yes No

Thyroid or Other Endocrine Disorder

Yes No

Anemia or Blood Disease

Yes No

Bleeding Disorder

Yes No

Tumor or Cancer

Yes No

Neurological Disease

Yes No

Seizures

Yes No

Stroke

Yes No

Tension Headache

Yes No

Migraine Headache

Yes No

Drug Addiction or Alcoholism

Yes No

Chemical Dependancy Treatment

Yes No

Mental or Nervous Disorder

Yes No

Other

Date	Surgery	Physician

Please list all surgeries you have had:

Do you use anticoagulants (such as heparin, coumadin, Fragmin, Lovenox, enoxaparin, Normiflo, ardeparin, Orgaran, danaparoid?)

Yes No

Medication	Dose	Frequency

[+] Add a Medication

Do you use any over-the-counter medications?

Yes No

Medication	Dose	Frequency

[+] Add a Medication

Do you use any recreational drugs or medications which were prescribed for someone else?

Yes No

Medication	Dose	Frequency

[+] Add a Medication

Please list all the medications you are allergic to and/or have had problems tolerating. Briefly list the specific allergy or problem which occured.

Medication	Allergy or Problem

[+] Add a Medication

Allergies

Social History

Do you smoke?

Yes No

If so, how many packs per day?
If stopped, when?

Do you consume alcohol?

Yes No

How much?
Have you ever felt you should cut down on your drinking?	Yes No
Have people annoyed you by criticizing your drinking?	Yes No
Have you ever felt bad or guilty about your drinking?	Yes No

Do you consume caffeinated beverages?

Yes No

How much?

Do you take prescription pain medications?

Yes No

If yes, do you take more than the prescribed amount?

Yes No

Have you ever been treated for substance abuse?

Yes No

If so, describe details?

Are you married?

Yes No Divorced Widowed

Do you live alone?

Yes No

Are you a care giver to anyone?

Yes No

Is there someone at home who can help you with activities of daily living?

Yes No

Family History

Is your father alive?

Yes No

Cause of death

What health problems does your father have?

Is your mother alive?

Yes No

Cause of death

What health problems does your mother have?

Do you have any blood relatives/children/siblings with significant medical problems?

Yes No

Explain

Behavioral Health

How has the pain affected your personality? Check all that apply.

no effect slighty upset moderately upset severely upset irritable anxious moody withdrawn unmotivated

What stress has the pain caused you at home/work?

Are you depressed now?

Yes No

Do you have thoughts of suicide?

Yes No

Do you want to see a behavioral health specialist to help you deal with the pain?

Yes No

Have you ever seen a counselor, psychologist, or psychiatrist?

Yes No

Please include their name, date last seen, and office number.

Review of Systems

Do you have? Check all that apply:

Constitutional

weight loss excess fatigue chills fever night sweats loss of appetite

Eyes

glasses/contacts vision changes eye pain tearing eye discharge

ENT/Mouth

earache ringing in ears hearing loss infections sore throat post nasal drip bleeding gums ear discharge

Cardiovascular

chest pain angina palpitations short of breath with activity or at rest heart murmur

Pulmonary

cough productive cough wheezing short of breath at rest asthma TB

Gastrointestinal

heartburn peptic ulcers nausea vomiting diarrhea constipation bloating laxative use jaundice loss of bowel control

Urological

frequent urination urinary tract infection painful urination urinary retention urinary dribbling loss of urinary control

Musculoskeletal

joint pain joint swelling joint stiffness muscle pain muscle stiffness

Endocrine

hot flashes hair loss always hot always cold always thirsty

Skin

itching rash infection

Blood

easy bruising easy bleeding anemia swollen lymph nodes

Immune compromise

AIDS steroid use frequent infections chemotherapy allergies hives

Neurological

numbness tingling tremor fainting headaches weakness dizziness

Psychological

anxiety depression insomnia nightmares mood swings

For men only

Do you have problems with erections?

Yes No

For women only

Could you be pregnant now?

Yes No

Date of last menstrual period

Current Employer

How many years have you worked for this employer?

Occupation (brief job description or type of work activity)

Are you working?

Yes No

If not working, when did you last work?
If not working, is pain preventing you from working?	Yes No
If not working, when will your off work slip expire?
If not working, would you like to return to work?	Yes No
If not working, who took you off work?

Are you on disability?

Yes No

If yes, when did your disability start?
If yes, what was the medical diagnosis?
If yes, which type of disability do you have? (check all that apply)	short term disability long term disability social security disability other

Are you on Workers Compensation (WC)?

Yes No

If yes, when did your WC start?
Is your WC claim in despute?	Yes No

If you are involved in a lawsuit(s), who is the lawsuit against? (check all that apply)

lawsuit regarding a disability claim
lawsuit regarding an auto accident
lawsuit with Workers Compensation
other

Diagnostics - What diagnostic studies, such as xrays, CT scans, MRI's, myelograms, EMG's(electromyogram), or bone scans have been done within the last 5 years? List below, including type of study, date completed, which part of the body was studied, and the hospital or office where the study was performed. For example: MRI - 2001 - low back - Sparrow

Diagnostic Test	Date	Part of Body	Location of Test

[+] Add a Diagnostic Study

Physicians, psychologists, or healthcare professionals involved in your care - List all physicians and mental health professionals you have consulted (including those for non-pain complaints):

Name	Date Last Seen	Office Phone #

[+] Add a Physician

Be sure that you have entered information in all fields before clicking Submit.

Sitemap | Privacy Policy & Terms of Use

Website Design by DDA Medical