PMC of Lansing
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Questionnaire

Patient's First Name
Patient's Last Name
Email
Today's Date
Date of Birth
Sex
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?
:
Describe the Problem
Briefly List
Treatments tried
Injections tried
Medications tried
Physical therapy tried
Have you had any previous...
When
facility name
When
facility name
When
facility name
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
USUAL PAIN
LEAST SEVERE PAIN
WORST PAIN

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

What does your pain feel like? (check all that apply)
Other, please describe:

What has been used to treat your pain? (check all that apply)
How many times have you been to the ER for pain control over the last 3 months?
Other, please describe:

What increases your pain? (check all that apply)
Other, please describe:

What decreases your pain? (check all that apply)
Other, please describe:
   
Does your pain keep you from falling asleep at night?
Does your pain awaken you at night?
   
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?
Do you have any weakness?
Do you have any changes in your bowel/bladder?
 
Past and Present Medical Problems
What are your past or current medical problems? (check all that apply)
Heart Disease
Rheumatic Fever
High Blood Pressure
Lung Disease
Bronchitis or Pneumonia
Asthma
Liver or Gall Bladder Problem
Hepatitis
Peptic Ulcer Disease
Colitis
Pancreatitis
Bladder or Kidney Disease
Arthritis
Diabetes
Thyroid or Other Endocrine Disorder
Anemia or Blood Disease
Bleeding Disorder
Tumor or Cancer
Neurological Disease
Seizures
Stroke
Tension Headache
Migraine Headache
Drug Addiction or Alcoholism
Chemical Dependancy Treatment
Mental or Nervous Disorder
Other
 
Please list all surgeries you have had:
Date Surgery Physician
     
Do you use anticoagulants (such as heparin, coumadin, Fragmin, Lovenox, enoxaparin, Normiflo, ardeparin, Orgaran, danaparoid?)
Medication Dose Frequency

[+] Add a Medication

Do you use any over-the-counter medications?
Medication Dose Frequency

[+] Add a Medication

Do you use any recreational drugs or medications which were prescribed for someone else?
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?
If so, how many packs per day?
If stopped, when?
Do you consume alcohol?
How much?
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Do you consume caffeinated beverages?
How much?
Do you take prescription pain medications?
If yes, do you take more than the prescribed amount?
Have you ever been treated for substance abuse?
If so, describe details?
Are you married?
Do you live alone?
Are you a care giver to anyone?
Is there someone at home who can help you with activities of daily living?
 
Family History
Is your father alive?
Cause of death
What health problems does your father have?
Is your mother alive?
Cause of death
What health problems does your mother have?
Do you have any blood relatives/children/siblings with significant medical problems?
Explain
 
Behavioral Health
How has the pain affected your personality? Check all that apply.
What stress has the pain caused you at home/work?
Are you depressed now?
Do you have thoughts of suicide?
Do you want to see a behavioral health specialist to help you deal with the pain?
Have you ever seen a counselor, psychologist, or psychiatrist?
Please include their name, date last seen, and office number.
 
Review of Systems
Do you have? Check all that apply:
Constitutional
Eyes
ENT/Mouth
Cardiovascular
Pulmonary
Gastrointestinal
Urological
Musculoskeletal
Endocrine
Skin
Blood
Immune compromise
Neurological
Psychological
 
For men only
Do you have problems with erections?
 
For women only
Could you be pregnant now?
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?
If not working, when did you last work?
If not working, is pain preventing you from working?
If not working, when will your off work slip expire?
If not working, would you like to return to work?
If not working, who took you off work?
   
Are you on disability?
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)




 
Are you on Workers Compensation (WC)?
If yes, when did your WC start?
Is your WC claim in despute?
   
If you are involved in a lawsuit(s), who is the lawsuit against? (check all that apply)




 
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.

 
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