INDEPENDANT MEDICAL EVALUATION (IME) QUESTIONNAIRE · Allevio pre-assessment questionnaire Allevio...

Allevio pre-assessment questionnaire Allevio Healthcare Inc. November 2015

INDEPENDANT MEDICAL EVALUATION (IME) QUESTIONNAIRE:

You have been referred by your lawyer or insurer for an independent medical assessment regarding the pain you have. Your assessor will be a licensed physician with a special interest in chronic pain management. Please complete this form and return by fax to (647) 427-4100 at least 1 week before your scheduled appointment. Your privacy is a priority – this information will remain confidential within our medical files.

TODAY’S DATE: _________________ NAME: _________________________________________________ Year/Month/Day First Middle Last

DATE OF ACCIDENT: ________________ DATE OF BIRTH: ____________________ Age: _____ Year/Month/Day Year/Month/Day

SEX: HEIGHT: _______ WEIGHT: ______ HANDED:

PLACE OF BIRTH: _____________ Year you immigrated to Canada: ____ LANGUAGE SPOKEN: ______________

TELEPHONE: __________________________________________________ EMAIL: _____________________ Home Work Cellular

DESCRIPTION OF INJURY/ACCIDENT: 1. Please describe the current injury:

a. What type of injury was this? Car accident Work Accident Slip and Fall

Other (describe, and clarify if there are more than one accidents to discuss):

b. What type of vehicle were you in? _____________________c. You were the:

d. Were you wearing a seatbelt?

e. Did the airbags open?

f. Did you lose consciousness?

g. Did you have pain immediately?

Male Female Le ft Right

Driver Passenger, front Passenger, back

No Yes

No Yes

No Yes Not Sure

No; when did it start? _________________________

Yes, where in the body?_______________________________

______________________________________________________

h. Who attended the scene? Polic e Param edic s N o one else

i. When did you first seek medical attention? __________________________

j. When did you first start physical therapy? ___________________________

1. Do you currently attend? Yes , How often? __________________ No

2. Circle one number to indicate how helpful you find physical therapy?

0 1 2 3 4 5 6 7 8 9Not at all

10 All of the time


k. List the medical tests and consultations (with approximate dates) you have had since the accident:

2. Since the accident, your overall pain has: increased decreased not changed fluctuated

3. Since the accident, your overall condition has:

4. Overall, to what extent do you feel the pain has interfered with your life?

0 1 2 3 4 5 6 7 8 9 10 Not at all Extreme interference

MEDICAL INFORMATION:

5. Have you been in any previous accidents or major injuries? N o Y e s , p l e a s e d e s c r i b e :

6. Family Doctor:

a. Before the accident: ____________________________________________________________

b. Now: ____________________________________________________________

c. If different, what is the reason for a change? ____________________________________________

increased decreased not changed fluctuated

7. Please check off and specify any major illnesses or surgeries you have had, and explain if they began

before or after the accident:

Illness/Surgery Yes No

Cancer in past 5 years

Smoking

Alcohol

Depression

Anxiety

Trauma

Mood Disorder

Psychiatric Illness

Addiction

Heart Attack/CHF

Heart Surgery

Before Accident SpecificationAfter

Accident

Illness/Surgery Yes No

Hypertension

Before Accident

SpecificationAfter Accident

Pacemaker or ICD

Sleep Apnea

COPD

Kidney Failure

Cirrhosis

Hepatitis B or C

HIV

Blood Disorder

Epilepsy/Seizures

Neuropathy

Rheumatoid Arthritis

Osteoarthritis

Joint Replacement

Spinal Surgery

Other:


Any additional information:

Allevio Healthcare Inc. November 2015 Allevio pre-assessment questionnaire

Name Dose TAKEN Times taken per day For what condition?

9. Allergies to medication:

8. List ALL medications you are currently taking (may attach list):

_______________________________________________________________________________________

SOCIAL HISTORY:

10. Where were you born? ____________________

11. Highest level of education attained? _________________

12. Type of degree: ________________

13. Total years of post-secondary education attended? _________________

14. Do you live in a:

a. Rental apartment

b. Rental town home

c. Own house

d. With your parents

e. Other

i. Please specify: ________________

15. Please describe if your living situation has changed since the accident: _____________________________

__________________________________________________________________________________________


16. Please describe your marital status?

separated for ____ year s divorced for ____ year s

a. Please describe how, if at all, your relationship has changed since the accident: ________________

____________________________________________________________________________________

b. How would you rate your relationship with your partner BEFORE the accident? Please circle the

number:

1 2 3 4 5 6 7 8 9 10 Poor Excellent

c. How would you rate your relationship with your partner NOW?

1 2 3 4 5 6 7 8 9 10 Poor Excellent

17. How many children do you have? __________ Ages? __________

a. To what extent has your ability to parent your children changed since the accident?

4 5 6 7 8 9 1 2 3 No interference

10 Extreme interference

b. Please describe how, if at all, your relationship with your children has changed since the accident:

single m arried for ____ years

in a s t a b l e r e l a t i o n s h i p for ____ years widowed

18. Prior to the accident, how did you like to spend your free time when not working? What hobbies or

recreational activities did you enjoy? Please be specific, including time spent each day or week.

a. Please describe how, if at all, these activities have changed since the accident:

Allevio Healthcare Inc. November 2015

19. Describe your typical day in the past few weeks:

n o t c h a n g e d i n c re a s e d d e c re a s e d , b y ___________ l b s

FUNCTIONAL STATUS:

20. Since the accident, your weight has:

21. Please describe your sleeping patterns:

Prior to injury After injury for 1 month Currently

Minutes to fall asleep

Hours per night, total

Times woken up

Restful or not restful

Hours resting during day

Nightmares about

accident

Nightmares about other

a. Your sleeping patterns are:

MENTAL HEALTH STATUS: 22. Please describe your mood and related symptoms:

improving getting worse stable for past month

Allevio pre-assessment questionnaire

Degree of improvement

Happy

Balanced

Energetic

Sad

Depressed

Worried

Anxious

Angry

Irritable

Fatigued

Getting WorseUnchanged in past months Improving


Yes N o a. Have you attending counselling since the accident?

1. If yes:

1. For how long? ____________

2. With who? _______________

How often? ____________ 3. Are you still attending?

4. Did you find it helpful?

Yes No

Ye s N o Unsure

Degree of improvement

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bƻ LƴǘŜǊŜǎǘ

9ƳǇǘȅ

bǳƳō

IƻǇƭŜǎǎ

Despairing

Unable to concentrate

Unable to cope

Want to be with people

Want to be alone

Getting WorseUnchanged in past months Improving

Other (please specify): ___________________

b. Describe other types of treatment or programs have you attended related to your mood since the

accident:


ACTIVITIES OF DAILY LIVING:

23. In terms of self-care activities, such as dressing, bathing and grooming:

I was fully capable and

independent with:

I needed some help with: I was unable to do the

following:

Prior to the accident:

After the accident:

Currently:

24. Please check off the box that best describes how difficult it has been to do each of the following in the past

few weeks?

Degree of difficulty None Slight Moderate Extreme Can’t do

Dress yourself

Shampoo/style hair

Get on and off toilet

Get in and out of bed

Walk outdoors on flat ground

Climb up 5 steps

Bend and pick-up clothing from floor

Get in and out of a car

Make meals

Degree of independance Able to do on your own

Require full assistance

Dust

Vacuum

Bathroom

Mopping

Dishes

Cooking

Folding Laundry

Lifting Laundry

Carrying Groceries

Lawn Care

Gardening

Shoveling

Able to do on your own

Require full assistance

Prior to Accident Currently

25. Please check off the box that best describes your degree of independence prior and after the accident:

OCCUPATIONAL HISTORY: N o Y e s, h o u r s p e r w e e k : ________________

N o

26. Were you working prior to the accident?

a. Occupation?________________________

27. Are you currently working?

28. Is it the same job as before the accident? N o

a. If no, please describe your job situation since the accident in detail:

Y e s , h o u r s p e r w e e k :________________

Y e s,



30. Have you required additional sick leave or time off for treatment since the accident?

a. On average, how many sick days did you take per 6 months before the accident?

b. On average, how many sick days do you take per 6 months over the past year?

No Yes

____________

_____________

Heavy Lifting

Light Lifting

Bending

Sitting

Twisting

Reaching Up

Typing

Concentration

Customer Service

Calculations

Quick Thinking

Other:

Job Prior to Accident Current Job (if different)

29. What are the physical and mental demands of your prior or current job?

31. Please describe how, if at all, your current condition affects your ability to perform your work:


32. Pain Levels:

a. Circle one number to indicate how much of the time you were in pain during the past 4 weeks:

0 1 2 3 4 5 6 7 8 9 10 Not at all All of the time

b. Please rate your worst pain over the past 4 weeks:

0 1 2 3 4 5 6 7 8 9 10 No Pain Worst pain imaginable

c. Please rate your least pain over the past 4 weeks:


d. Please rate your average pain over the past 4 weeks:


33. Location of CURRENT pain: Please mark an “X” on the area(s) where you feel pain on these drawings:

List the painful sites from worst pain to least pain: _______ >________ > _______ > _______ > _______

Allevio Healthcare Inc. November 2015

34. Quality of pain: List each of the areas of your pain in the table below and place an “X” beside each

of the words that best describe your pain.

List the Pain Location:

a. b. c. d. e.

Constant

Comes and goes

Sharp

Shooting

Stabbing

Throbbing

Aching

Tight

Burning

Cramping

Other:

Other:

If more than 5 pain sites, please describe:

Allevio pre-assessment questionnaire

Worst Pain Least Pain

35. Which of the following symptoms do you experience? (Check only the ones that apply)a. Bowel Incontinence (soiling yourself)

b. Urinary Incontinence (wetting yourself)

c. Night Sweats

d. Unintended Weight Loss

e. Weakness resulting in falls or dropping things

f. Numbness pins/needles tingling

right left

I. Where? ___________________

i. Shooting pain down the arm(s); which one?

ii. Shooting pain down the leg(s); which one? right left


36. Describe everything that aggravates your pain, for each of the sites listed above (in same order):

37. Check off everything that relieves your pain, even mildly or temporarily:

restmedication sleep exercise

relaxation injections swimming

bending stretching physical therapy

other: __________________________________

List the Pain Location:

a. b. c. d. e.

Lifting

Bending

Walking

Standing

Sitting

Climbing Stairs

Couging

Sneezing

Looking Up

Looking Down

Turning the Head:

Reading:

Thinking

Stress

After Sleep

Other:

If more than 5 pain sites, please describe:


Pain Disability Questionnaire (PDQ)

Patient Name: ________________________________________ Date:______________________________

Instructions: These questions ask your views about how your pain now affects how you function in everyday

activities. Please answer every question and circle the ONE whole number on EACH scale that best describes

how you feel.

1. Does your pain interfere with your normal work inside and outside the home?

Work normally Unable to work at all 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

2. Does your pain interfere with personal care (such as washing, dressing, etc)?

Take care of myself completely Need help with all personal care 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

3. Does your pain interfere with your traveling?

Travel anywhere I like Only travel to see doctors 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

4. Does your pain affect your ability to sit or stand?

No problems Cannot sit/stand at all 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things?

No problems Cannot do at all 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat?

No problems Cannot do at all 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

7. Does your pain affect your ability to walk or run?

No problems Cannot walk or run at all 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10


8. Has your income declined since your pain began?

No declineLost all income

0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

9. Do you have to take pain medication every day to control your pain?No medication needed On pain medication throughout the day 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

10. Does your pain force you to see doctors much more often than before your pain began?

Never see doctors See doctors weekly 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

11. Does your pain interfere with your ability to see people who are important to you as much as you would like?

No problem Neversee them0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

12. Does your pain interfere with recreational activities and hobbies that are important to you?

No interference Total interference 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

13. Do you need the help of your family and friends to complete everyday tasks (including both work outside the

home and housework) because of your pain?

Never need help Need help allthe time0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

14. Do you now feel more depressed, tense, or anxious than before your pain began?

Severe No depression/tension0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

15. Are these emotional problems caused by your pain that interfere with your family, social and/or work

activities?

No problems 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10

Thank you for taking the time to complete this and return to us.

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