Slucare Pain Management Center

SLUCare Pain Management Center PATIENT QUESTIONNAIRE Patient’s Last Name: First: Middle: Medical Record #: (for office use)

Appointment Date: Appointment Time:

Primary Care Physician: Date of Last Visit to PCP:

Phone #: Referring Physician If Not PCP: Phone #: ( ) - ( ) - Date pain started: Briefly describe your primary pain complaint:

Do you have pain in other locations? Yes No If yes, please specify:

Pain radiates to my: Type of pain: Pain characteristics: (choose one)

Head Arm Back Burning Aching Right side Middle only

Neck Chest Hip Numbness Stabbing Left side Everywhere

Shoulder Abdomen Leg Tingling Both sides

Pain caused by: If work injury: Did you hire an attorney? No specific event Date: Yes No

Work injury Ins Co: Is a lawsuit pending? Car accident Case manager: Yes No Surgery Claim #:

Choose the number that describes your pain: Rate the quality of your sleep: /10 (0=no pain and 10 worst pain imaginable) (0= not at all restful and 10= completely restful) Pain pattern /10 Pain intensity now Do you have difficulty GETTING to sleep? Continuous /10 Pain at its least Yes No Comes and goes / 10 Pain at its worst Do you have difficulty STAYING asleep? Brief momentary / 10 Pain on average Yes No

Where is your pain?

SLUCare Pain Management Department  PHONE (314) 977-5400  FAX (314) 977-5404  Last Updated May 2009 Using the symbols listed below, mark on the drawing the areas where you feel your pain. If you feel more than one sensation in the same area, mark over that area with the additional symbols that apply. Please indicate all affected areas.

SYMBOLS:

Numbness Pins and Burning Stabbing Aching External Internal Needles (on or (inside) outside) ------OOOOOO xxxxxxxxx //////////// +++++++ E I /

Right Left Left Right

SLUCare Pain Management Department  PHONE (314) 977-5400  FAX (314) 977-5404  Last Updated May 2009 MEDICINES Medicine: Amount / # Times Per Day: Reason For Taking:

MEDICAL PROBLEMS AND SURGERIES Please list your medical problems and surgeries including dates if possible:

ALLERGIES Any known allergies? Yes No If yes, please list any medications or foods you are allergic to:

Listed below are procedures commonly used in treating pain. If you have used any of the below treatments, please indicate the amount of benefit you experienced.

Surgery Helpful Not Helpful Worse Steroid Injection Helpful Not Helpful Worse Physical therapy Helpful Not Helpful Worse Aquatic therapy Helpful Not Helpful Worse TENS unit Helpful Not Helpful Worse Biofeedback Helpful Not Helpful Worse Psych Counseling Helpful Not Helpful Worse Other: Helpful Not Helpful Worse

of 5 PERSONAL HEALTH HISTORY

SLUCare Pain Management Department  PHONE (314) 977-5400  FAX (314) 977-5404  Last Updated May 2009 Please indicate whether you currently have (C), or previously have had (P), any of the following conditions. All information is strictly confidential.

C P C P C P

Constitutional Symptoms Genitals / Bladder Muscle / Joints Fever Painful urination Arthritis Fatigue Bladder Infection Bursitis Eye Difficult Urination Fibromyalgia Eye Pain Frequent Urination Poor Posture Blurred Vision Blood in Urine Sciatica Glaucoma Testicle Problem Spinal Curvature Eye Discharge Flank Pain Swollen Joints Glasses or Contacts STD Joint Replacement Light Sensitivity Nocturia Back Surgery Sexual Dysfunction Ear Hot Flashes Ear Discharge Pain and /or Numbness Menstrual Cramps Arms Ringing or Pain Excessive Menstruation Shoulder Hearing Difficulty /Aids Irregular Menstruation Hands Menopause Elbows Nose Painful Menstruation Neck Pain Vaginal Discharge Hips Discharge Pain on Intercourse Legs Congestion Kidney Disease Knees Eye Discharge Feet Glasses or Contacts Tailbone Lungs Painful Breathing Mouth / Throat Allergic / Other Denture Productive Cough Hay Fever Jaw/ tooth pain Bronchitis Allergies (not drugs) Mouth Sores Sore Pneumonia Cancer Throat Emphysema AIDS/HIV Hoarseness Shortness of Breath Lupus

TB Nutrition Asthma Weight Loss/ Gain Poor Appetite Nutritional Supplement

C P C P C P Heart Skin / Breast Brain / Nerves

SLUCare Pain Management Department  PHONE (314) 977-5400  FAX (314) 977-5404  Last Updated May 2009 High Blood Pressure Skin Rash Headache Chest Pain Itching Multiple Sclerosis Heart Attack Easy Bruising Seizures Abnormal Heart Rhythm Shingles Head Injury Swelling of Ankles Skin Cancer Stroke Pacemaker Lumps in Breasts Tremors Blood Clot Congested Breasts Dizziness Blood Thinners Light Sensitivity Stomach / Bowels Loss of Coordination Blood/ Glands Sweats Abdominal Pain Memory Loss Thyroid Disease Heartburn Alzheimer’s Diabetes Hiatal Hernia Depression Leukemia Nausea/ Vomiting Anxiety Bruising Constipation Alcoholism Bleeding Disorder Diarrhea Thoughts of Suicide Swollen Glands Ulcers Irritability Liver/Gallbladder Issues Weakness Black, Bloody Stool Numbness/Tingling

Family Medical History: Has anyone in your family ever had any of the following?

FATHER MOTHER BROTHER SISTER GRANDPARENT ANXIETY CANCER CHRONIC PAIN DEPRESSION DIABETES HEART DISEASE HIGH BLOOD PRESSURE PHYSICAL DISABILITY SCHIZOPHRENIA STROKE SUICIDE THYROID DISEASE

Social History:

Substance Abuse Quantity (circle per day or per week)

Beer per DAY / per WEEK

Alcoholic Beverages per DAY / per WEEK

Use of Tobacco per DAY / per WEEK

Illegal Drugs per DAY / per WEEK

Retired Employed Unemployed Marital Status: Occupation:

SLUCare Pain Management Department  PHONE (314) 977-5400  FAX (314) 977-5404  Last Updated May 2009