Pain Relief Associatesnew Patient Intake

PAIN RELIEF ASSOCIATESNEW PATIENT INTAKE

Name: ______Date of Birth: ______/______/______Age: ______

Address: ______City: ______State: ______ZIP: ______

Best Phone Number to Reach You: ______Email: ______

Social Security #: ______Employer: ______Job Description: ______

Marital Status:M S D W Children (names and ages): ______

Spouse Name: ______Spouse Employer: ______

Primary Care Physician: ______Phone: ______

Chief Complaint (Why are you seeing the doctor today?): ______

Please circle the area(s) of the body where you are experiencing symptoms and mark the circled area(s) with:

“BP” for burning pain, “SHP” for sharp pain, “STP” for stabbing pain, “DP” for dull pain, “AP” for achy pain, “N” for numbness, and “T” for tingling

Timing of Pain/ Alleviating and Aggravating Factors:

What makes your pain feel better? ______

What makes your pain feel worse? ______

Duration of Pain:

How long have you had the pain you are currently experiencing (Or, date of the injury)? ______

What caused your current pain to start? ______

How often do you have your pain?

______a. Constantly (80-100% of the time)______c. Intermittently (25-50% of the time)

______b. Nearly Constant (50-80% of the time)______d. Occasionally (less than 25% of the time)

Past Treatment:

Treatment / Did it give you relief? For how long? / When and why did you discontinue?

Do you have any known (drug) allergies? (Explain)______

Education: K-8 ___ High School ___ 2 Year College___ College Graduate ___ Post Graduate ___

Do you or have you ever smoked cigarettes, cigars or pipes? Yes / No If Yes, How long? ______

How many packs per day? ______Age you started: ____ Have you quit? Yes / No When? ______

Do you consume alcohol? Yes / No Number of drinks per day, week, or month: ______

Have you ever undergone treatment for drug or alcohol addiction? Yes / No

Have you had any of the following conditions?

Please List any Hospitalization or Surgery Dates: ______

FAMILY MEDICAL HISTORY:

Father: ______Alive? ______State of Health: ______

Deceased? ______Age at Death: ______Cause of Death: ______

Mother: ______Alive? ______State of Health: ______

Deceased? ______Age at Death: ______Cause of Death: ______

Grandparent / Age / Sex / Illness, Congenital Abnormalities or Cause of Death

Medications: Please list any medications, dosage, how many times per day and for how long:

Medication / Dosage / How Often? / When Did You Start? / Comments

Please circle YES or NO to the following question.

Do you have weakness in your legs, feet, arms, or hands? Yes NoDetails______
Do you have numbness in your legs, feet, arms, or hands? Yes NoDetails______
Do you suffer from burning in your legs or feet? Yes NoDetails______
Do your legs or feet ever fall asleep? Yes NoDetails______
Do you have back pain? Yes NoHow often?______
Do you ever have headaches? Yes NoHow often?______
Do you often trip or catch your toe while walking? Yes NoDetails______
Have you ever been diagnosed with arthritis? Yes NoDetails______
Do you ever suffer from dizziness? Yes NoDetails______
Do you have difficulty maintaining your balance? Yes NoDetails______
Do your knees crack, pop, or give you pain? Yes NoDetails______

Activity:

Circle the number that best describes how your pain has interfered with your:

Does Not InterfereCompletely Interferes

Bending:12345678910
Changing Position (Sit-Stand)12345678910
Sitting:12345678910
Standing:12345678910
Lifting:12345678910
Walking:12345678910
Kneeling: 12345678910
Climbing Stairs:12345678910
Sleeping:12345678910
Driving:12345678910
Taking Care of Children:12345678910
Household Chores:12345678910
Yard Work12345678910
Extended Computer Use:12345678910
Bathing:12345678910
Getting Dressed:12345678910
Self-Care:12345678910
Sexual Activities:12345678910
Pet Care:12345678910
Reading:12345678910
Family Relationships:12345678910
Relationship with Spouse/Partner:12345678910
Social Activities with Others:12345678910
Work/Job Duties:12345678910
Concentration:12345678910
Mood:12345678910
Enjoyment of Life:12345678910

TREATMENT GOALS - Please list the specific goals you would like to achieve through treatment (i.e., golf, sleep, work, etc):

______

What is your single most important reason for wanting to reduce or eliminate your pain?

______