Microsoft word - new patient questionnaire.doc

Name: ____________________________ D.O.B. ____________________________ Name:
Age:
Sex:
Date:
Referring Physician:

• Where is your pain? (Please circle all that apply)

Back, Neck, Right Leg, Left Leg, Right Arm, Left Arm, Chest, Abdomen, Head, Face, Groin, Other _________________________________________________. • When did the pain first start? (Month and Year)
• How did the pain start? (Please circle all that apply)

Injury at work, Injury not at work, Accident, Surgery, Infection, No known cause, Other____________________________________________________________.
• Did the pain start gradually or suddenly?
• Is the pain constant or comes and goes (intermittent)?
• If intermittent what is the frequency of pain attacks and how long does each
attack last? (Example – four times a day and lasts for half-hour)
• Does the pain radiate (move or shoot) anywhere?
• Is the pain burning in nature anywhere?
• Is there numbness or tingling anywhere?
• Are any of the painful areas hypersensitive to touch?
• Is there any itching in the area of pain?
Name: ____________________________ D.O.B.____________________________ • How would you describe the pain? (Please circle all that apply)

Aching, Burning, Stabbing, Crampy, Sharp, Dull, Deep, Superficial, Knife-like, Throbbing, Shooting, Electric, Pins and needles, Other_____________________.
• What makes the pain better? (Please circle all that apply)
Ice, Heat, Warm weather, Cold weather, Activity, Distraction, Pain medication, Standing, Sitting, Lying down, Walking, Bending forward, backward or sideward,
Changing positions, Other____________________________________________.
• What makes the pain worse? (Please circle all that apply)

Damp and Rainy weather, Activity and Stress, Ice, Heat, Warm weather, Cold weather, Activity, Distraction, Pain medication, Standing, Sitting, Lying down, Walking, Bending forward, backward or sideward, Changing positions, Other____________________________________________________________. • When did you first seek medical care for this pain problem?
• What have you done for pain control until now since it started? (Please circle all
that apply)

Surgery, Physical Therapy, TENS Unit, Sessions with pain psychologist, Epidural injections, Injection into the muscle, Other injections, Medications, Acupuncture, Chiropractor, Other___________________________. • Have you been to a pain clinic before:
• What investigations (studies) have you had so far for this problem? (Please
circle all that apply)

X-ray, CT scans, MRI scans, EMG, Bone scans, Myelograms.
• Does that pain wake you up at night?
• Does the pain make you depressed? Please rate on a scale of 0 to 10 (0 is pain
does not affect my mood in any way and 10 is pain makes me highly depressed)
• Please rate your pain level on a scale of 0 to 10. (0 is no pain and 10 is the worst
pain you could ever imagine)


• Are you able to function 100% (able to do all you wanted to do)?


• If no to the previous question, When were you last able to function 100% (able
to do all you wanted to do)?

• Compared to when you were functioning at 100%, how would you rate your
current functional level? (Please circle)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
• Are you employed?

No – Retired, Homemaker, Disabled, Other:________________________
• If no to previous question, since when are you unemployed?
● Do you drive a commercial vehicle such as a truck or school bus?


• Are you receiving disability benefits for this pain problem or for any other
medical problem?


• If yes, please specify:

Temporary, Permanent, Social Security, BWC, Other_____________________
• If you are not currently receiving disability benefits, are you planning to apply
for disability?


• Is litigation (law suit) regarding this pain problem:

Pending – Yes or No
Possible in future – Yes or No
Settled – Yes or No
• List all of your medical problems:
• List all the surgeries you have had:
● Do you have a pacemaker?
● Do you have a defibrillator?
● Have you ever been diagnosed with MRSA of the body or the spine?

• Are you on any blood thinner?:

(If yes, please circle all that apply)
Coumadin (warfarin), lovenox, heparin, plavix (clopidogrel), pletal (cilostazol), aggrenox (dipyridamole), ticlid (ticlopidine), trental (pentoxifylline), elmiron,
• List all your medications (with doses):
• List all of your drug allergies:
• Do you:
Smoke – Current everyday smoker Current some day smoker Former Smoker
Consume Alcohol – Yes or No
Abuse Drugs – Yes or No
Smoke Marijuana (Pot) – Yes or No

• Have you ever abused alcohol?


• Have you ever abused street drugs (marijuana, cocaine, ecstasy, crack cocaine,
heroin, etc.) or prescription drugs?


• Does anyone in your family abuse drugs?
• Have you tried any of these medications for pain control:

1. Baclofen
2. Ultram
3. Neurontin
4. Elavil / Amitriptyline
5. Celebrex
7. Flexeril
8. Zanaflex
9. Robaxin
10. Skelaxin

• Please list all other physicians who have treated you for pain in the last six
months:
I hereby verify that all of the above information is true to the best of my knowledge Patient Signature __________________________________________________
Physical Examination
HEENT:
CVS:
RESPIRATORY:
CNS:
SPECIFIC EXAM:
ASSESMENT AND PLAN:

Source: http://www.atlurimd.com/binary/org/SJM_PSP_376/new%20patient%20questionnaire.pdf