Pain Management Center HEALTH ASSESSMENT Pain Management Center Page 4 of 4 HEALTH ASSESSMENT Page 1 of 4 Review of Symptoms: Headache YES NO Diarrhea YES NO DATE: Palpitations YES NO Bladder/Bowel YES NO NAME: DOB: Chronic Cough YES NO Incontinence YES NO REFERRING MD: PRIMARY MD: Heartburn YES NO Heat Tolerance YES NO ADDRESS: ADDRESS: Blood in Urine YES NO Weakness YES NO Thrist/Polyuria YES NO Shortness of Breath YES NO Visual Problems YES NO Constipation YES NO PHONE: PHONE: Chest Pain YES NO Swelling YES NO Chief Complaint: Wheezing YES NO Other YES NO Please briefly state the main reason you are here today. For example: low back pain, headache, right shoulder pain, etc. This is the end of the patient section, the rest of the information will be filled in by your doctor or nurse. History of Illness: Patient Signature: Date: When did the pain first start? Pre-Procedure Evaluation How did your pain start? History of present Illness: Was it the result of an accident or injury? YES NO Are you involved in litigation (a lawsuit?) YES NO Is Worker’s Compensation involved in your injury? YES NO Does the pain radiate from this part of your body to another area? If yes, where? Please check the words that best describe your pain: BP: Pulse: Ht: Wt: VNS: ACHING HOT SHOOTING SHARP COLD NAGGING Physical Exam: BURNING NUMB SEVERE STABBING TINGLING OTHER: Airways: Lung: Heart: ASA: Please indicate on the chart where your pain is: Musculoskeletal: Neurological: Diagnosis: Plan of Procedure: CL0300 FRONT BACK LEFT SIDE RIGHT SIDE Please circle the number on the scale of 0 - 10 that represents your pain: 0 1 2 3 4 5 6 7 8 9 10 no pain severe pain X , MD _____/_____/_____ ___ ___ : ___ ___ PC 007 10/12 Signature Pager # Date Time Pain Management Center Pain Management Center HEALTH ASSESSMENT HEALTH ASSESSMENT Page 2 of 4 Page 3 of 4 Date: Date: Is your pain constant or intermittent? Constant Intermittent Past Medical History: If your pain is intermittent, is there a time of day when your pain is usually worse or better? Do you have history of any of the following? Worse AM/PM Better AM/PM Chest Pain YES NO Stroke YES NO Are there activities which make your pain worse (example: walking, sitting, stair climbing, etc.)? Heart Attack YES NO Ulcer Disease YES NO High Blood Pressure YES NO Diabetes YES NO What makes your pain better? Congestive Heart Failure YES NO Thyroid Problem YES NO Abnormal Heart Rhythm YES NO Anemia YES NO Asthma YES NO Bleeding Disorders YES NO Please check any diagnositc tests you have had for this condition: Pneumonia YES NO Arthritis YES NO MRI CAT SCAN EMG OTHER: Kidney Failure YES NO Psychiatric Disorder YES NO Please check any treatment you have had for pain: Prostate Trouble YES NO Cancer YES NO Liver Failure YES NO HIV YES NO ACUPUNCTURE NERVE BLOCK or other STEROID INJECTIONS Hepatitis YES NO Are You Pregnant YES NO CHIROPRACTOR PHYSICAL / AQUA THERAPY Seizure YES NO HEAT / COLD SURGERY MASSAGE TENS Past Surgical History: MEDICATIONS OTHER: Check this box if you have never had surgery. Please list any surgical procedures that you have had and the date of surgery Current Medications: Surgery: Date of operation: All other medications not for pain. Medication: Amount (mg.) Frequency What is it for? Family History: Please list any diseases that run in your family, for example; diabetes, heart disease, cancer, etc. Pain Medications: Please list any pain medications you are taking now or have in the past to treat your pain. Medication: Amount Has it Helped? Prescribed by: Social History: YES NO Do you smoke? YES NO If so how much? YES NO Do you drink alcohol YES NO If so how much? YES NO CL0300 Have you ever had a problem with alcoholism? YES NO Do you have any history of using Marijuana, Cocaine, Heroin, or any other illegal drugs? YES NO YES NO CL0300 If yes which drugs? YES NO Marital Status: single married divorced widowed committed relationship Allergies: Work Status: working not working retired disabled Check this box if you have no known drug allergies. Disability: temporary permanent Please list any medications that you are allergic to and the adverse reaction you have. Reason for disability: Medication: Adverse reaction Pain Management Center Pain Management Center HEALTH ASSESSMENT HEALTH ASSESSMENT Page 2 of 4 Page 3 of 4 Date: Date: Is your pain constant or intermittent? Constant Intermittent Past Medical History: If your pain is intermittent, is there a time of day when your pain is usually worse or better? Do you have history of any of the following? Worse AM/PM Better AM/PM Chest Pain YES NO Stroke YES NO Are there activities which make your pain worse (example: walking, sitting, stair climbing, etc.)? Heart Attack YES NO Ulcer Disease YES NO High Blood Pressure YES NO Diabetes YES NO What makes your pain better? Congestive Heart Failure YES NO Thyroid Problem YES NO Abnormal Heart Rhythm YES NO Anemia YES NO Asthma YES NO Bleeding Disorders YES NO Please check any diagnositc tests you have had for this condition: Pneumonia YES NO Arthritis YES NO MRI CAT SCAN EMG OTHER: Kidney Failure YES NO Psychiatric Disorder YES NO Please check any treatment you have had for pain: Prostate Trouble YES NO Cancer YES NO Liver Failure YES NO HIV YES NO ACUPUNCTURE NERVE BLOCK or other STEROID INJECTIONS Hepatitis YES NO Are You Pregnant YES NO CHIROPRACTOR PHYSICAL / AQUA THERAPY Seizure YES NO HEAT / COLD SURGERY MASSAGE TENS Past Surgical History: MEDICATIONS OTHER: Check this box if you have never had surgery. Please list any surgical procedures that you have had and the date of surgery Current Medications: Surgery: Date of operation: All other medications not for pain. Medication: Amount (mg.) Frequency What is it for? Family History: Please list any diseases that run in your family, for example; diabetes, heart disease, cancer, etc. Pain Medications: Please list any pain medications you are taking now or have in the past to treat your pain. Medication: Amount Has it Helped? Prescribed by: Social History: YES NO Do you smoke? YES NO If so how much? YES NO Do you drink alcohol YES NO If so how much? YES NO CL0300 Have you ever had a problem with alcoholism? YES NO Do you have any history of using Marijuana, Cocaine, Heroin, or any other illegal drugs? YES NO YES NO CL0300 If yes which drugs? YES NO Marital Status: single married divorced widowed committed relationship Allergies: Work Status: working not working retired disabled Check this box if you have no known drug allergies. Disability: temporary permanent Please list any medications that you are allergic to and the adverse reaction you have. Reason for disability: Medication: Adverse reaction Pain Management Center HEALTH ASSESSMENT Pain Management Center Page 4 of 4 HEALTH ASSESSMENT Page 1 of 4 Review of Symptoms: Headache YES NO Diarrhea YES NO DATE: Palpitations YES NO Bladder/Bowel YES NO NAME: DOB: Chronic Cough YES NO Incontinence YES NO REFERRING MD: PRIMARY MD: Heartburn YES NO Heat Tolerance YES NO ADDRESS: ADDRESS: Blood in Urine YES NO Weakness YES NO Thrist/Polyuria YES NO Shortness of Breath YES NO Visual Problems YES NO Constipation YES NO PHONE: PHONE: Chest Pain YES NO Swelling YES NO Chief Complaint: Wheezing YES NO Other YES NO Please briefly state the main reason you are here today. For example: low back pain, headache, right shoulder pain, etc. This is the end of the patient section, the rest of the information will be filled in by your doctor or nurse. History of Illness: Patient Signature: Date: When did the pain first start? Pre-Procedure Evaluation How did your pain start? History of present Illness: Was it the result of an accident or injury? YES NO Are you involved in litigation (a lawsuit?) YES NO Is Worker’s Compensation involved in your injury? YES NO Does the pain radiate from this part of your body to another area? If yes, where? Please check the words that best describe your pain: BP: Pulse: Ht: Wt: VNS: ACHING HOT SHOOTING SHARP COLD NAGGING Physical Exam: BURNING NUMB SEVERE STABBING TINGLING OTHER: Airways: Lung: Heart: ASA: Please indicate on the chart where your pain is: Musculoskeletal: Neurological: Diagnosis: Plan of Procedure: CL0300 FRONT BACK LEFT SIDE RIGHT SIDE Please circle the number on the scale of 0 - 10 that represents your pain: 0 1 2 3 4 5 6 7 8 9 10 no pain severe pain X , MD _____/_____/_____ ___ ___ : ___ ___ PC 007 10/12 Signature Pager # Date Time.