Revised 2/28/18

PAINMANAGEMENTQUESTIONNAIRE

Date:________/________/________PatientName:____________________________________________DOB:________/________/________

ReferringPhysician:________________________________________________________________________

PrimaryCarePhysician:_____________________________________________________________________

Pharmacy:________________________________________________________________________________

Haveyouhadanyimagingoftheareayouareheretohaveevaluated:□Yes□No IfYes,When:__________/__________/__________Where:_______________________________________________________________________

Reasonforappointment/Reasonyouwerereferred:□BackPain□NeckPain□Arm/LegPain□Shingles

□AbdominalPain□Cancer□Headaches□CRPS□Other:__________

***Pleasefillouttherestofthisformonlyforthepainassociatedwiththeareayoumarkedabove***! Haveyouhadthispainbefore:□Yes□NoIfYes,When:________________________________

! Pleasedescribehowyourpainbegan:_______________________________________________________

! Doyouhaveweaknessofyourextremities:□Yes□NoIfYes,Where:□LeftLeg□RightLeg□LeftArm□RightArm

! Doyouhavenumbness(inabilitytofeel):□Yes□NoIfYes,Where:__________________________________________

! Doyouhavetingling:□Yes□NoIfYes,Where:______________________________________

! Doyouhavelossofcontrolofyour:□Bowel□Bladder IfYes,

Haveyouexperiencedthisforalongtime:□Yes□NoDoesitonlyhappenwithcoughing/sneezing:□Yes□NoIsitdifficulttogo: □Yes□NoHaveyouhadanyaccidents: □Yes□NoIfYes,Howoften:_________

Page1

Revised 2/28/18

PatientName:_____________________________________________________________________________! Doesthepaininterruptyoursleep:□Yes□No

! Haveyouhadanyun-purposeful□Weightloss□WeightgainIfYes,Howmuch:_________pounds Whendidthisoccur:______________________________

! Doyouwakeupatnightsweatingorsoakingwet:□Yes□NoIfYes,Howoften:______________ Howlonghaveyoubeenexperiencing:______________

! Haveyoubeenseenbyanotherpainclinicinthepast:□Yes□NoIfYes,When:__________/__________/__________-__________/__________/__________

Who/Where:__________________________________________________________________

! Haveyouhadanypreviouspainmanagementinjections:□Yes□No IfYes,Whattype:___________________________________________Didithelp:□Yes□No ___________________________________________Didithelp:□Yes□No ___________________________________________Didithelp:□Yes□No

! Haveyouhadphysicaltherapy:□Yes□No IfYes,When:__________/__________/__________-__________/__________/__________Who/Where:__________________________________________________________________ Didyoulearnahometherapyprogram:□Yes□No

! Haveyouseenachiropractor:□Yes□No IfYes,When:__________/__________/__________-__________/__________/__________Who/Where:__________________________________________________________________

! Haveyouseenapainpsychologist:□Yes□No IfYes,When:__________/__________/__________-__________/__________/__________Who/Where:__________________________________________________________________ Didyoulearn:□Biofeedback□Copingskills□Relaxationmethods

! Haveyouhadacupuncture:□Yes□NoIfYes,When:__________/__________/__________Didithelp:□Yes□No

! HaveyouusedaTENSunit(electricalstimulationoftheskin):□Yes□NoIfYes,When:__________/__________/__________Didithelp:□Yes□No

Page2

Revised 2/28/18

PatientName:_____________________________________________________________________________

PainLocation-Onthefiguresbelow,usingthesymbolslsitedbelow,pleasemarktheareasofyourbodywhereyoufeel:

Numbness==== Stabbing//// BurningxxxxPin&Needlesoooo Aching(((( Areawhereithurtsthemost√

Page3

Revised 2/28/18

PatientName:_____________________________________________________________________________

AddressingthePersonalSideofLivingwithChronicPain

Asanindividuallivingwithpersistentchronicpaineveryday,youarefullyawarethatyourPAINdoesNOTjustaffectyouphysically.Chronicpaintoucheseverypartofyourlife.Yourpainaffectsyouemotionally,mentallyandspiritually.Livingwithpainhasanimpactonyourrolesinlife,yourrelationships,yourwork,yourhobbies,yourrecreationalactivitiesandtheoverallqualityofyourlife.Therefore,forustoeffectivelyaddresshelpingyoumanageyourpain,pleaseanswerthefollowingquestions.

1. Haveyoustruggledtomanageyourpainbyusingthe“olestiffupperlip” □Yes□Noor“toughitout”method?

2. Haveyoulostyourjob,missedasignificantamountofworkorstopped □Yes□No

physicalorrecreationalactivities?

3. Doyoufeelyouhavelostmeaningandpurposeinyourlife? □Yes□No

4. Haslivingwithpainchangedyourrolesinlifeasanemployee,spouse, □Yes□Noparent,etc.?

5. Doyoufeelyouhavefailedorletotherdownbynotbeingableto“DO” □Yes□Noasyouoncedid?

6. Doyoufeelyourpainisoftenincontrolofyourlife:? □Yes□No

7. Doyoufindyourmoodsbouncingaround,attimesyoufeeldepressed, □Yes□Noangryoranxious?

8. Dofamily/friendsseemtostruggletounderstandwhatitislikeforyou □Yes□Notolivewithchronicpain?

9. Doyoufeeljudgedattimes? □Yes□No

10. Doyoustrugglesometimesmakingadecisionaboutanactivityworrying □Yes□No

thatitwillresultina“flareup”?

11. Haveyounoticedthatasyourstresslevelincreasessodoesyourpain? □Yes□No

12. Doyoufinditdifficultto“relax”or“calm”yourselfasyougothrough □Yes□Noyourdaywithpain?

Pleasesharewithusanycommentsyouhaveregardingthescreeningquestionsoranypersonalconcernsordifficultiesyouhavelivingwithyourpain:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Page4

Revised 2/28/18

PatientName:_____________________________________________________________________________

BACKPAIN

! Isyourwalkinglimited:□Yes□No

Ifyes,howfarcanyouwalkwithoutstoppingtorest:___________________________blocks/miles

! Doesbendingoverholdingontoashoppingcart,etc.allowyoutowalkfarther:□Yes□No

! Whatpercentageinintheback:________%Whatpercentageisintheleg(s):________%

Pleasecheckallthatapply.

(whatcausedonsetofpain)

Page5

Revised 2/28/18

PatientName:_____________________________________________________________________________

ABDOMINALPAIN

Pleasecheckallthatapply.

(whatcausedonsetofpain)

Page5

Revised 2/28/18

PatientName:_____________________________________________________________________________

NECKPAIN

! Whatpercentageinintheneck:________%

! Whatpercentageisinthearm(s):________%

Pleasecheckallthatapply.

(whatcausedonsetofpain)

Page5

Revised 2/28/18

PatientName:_____________________________________________________________________________

ARM/LEGPAIN

! Doesyouraffectedextremitychangecolor:□Yes□No

! Doesyouraffectedextremityfeel:□warmer□colder

! Doesyouraffectedextremityswell:□Yes□No

! Doeslighttouchworsenyourpain(puttingonsocks,sheetsonthebed):□Yes□No

! Haveyounoticed□hair□nailgrowthontheaffectedextremity:□Yes□No

Pleasecheckallthatapply.

Whatcausedonsetofpain:

Page5

Revised 2/28/18

PatientName:_____________________________________________________________________________

HEADACHES

! Arethereanysignsthatyourheadacheisgoingtohappen:□Yes□No

IfYes,whatarethesigns:______________________________________________________________

! Howmanyhoursdoyourheadachestypicallylast?_______________

Pleasecheckallthatapply.

PatientName:_____________________________________________________________________________

0=NoPain10=Painasbadasyoucanimagine

(sound)(light)

(whatcausesonsetofpain)

Page5

Revised 2/28/18

PatientName:_____________________________________________________________________________(0=Nopain/10=Painasbadasyoucanimagine)

MEDICATIONS-PleaselistALLmedications,includingherbalandover-the-counter:

Drug Dose PrescribingProvider

ALLERGIES-Drug/Item Reaction

Page6

Revised 2/28/18

PatientName:_____________________________________________________________________________

REVIEWOFSYSTEMS-Pleasemarkallcurrentorchronicconditions:

Constitutional Genitourinary-FEMALE Neurological□Chills □Dysuria(painfulurination) □Dizziness□Fatigue □Hematuria(bloodyurine) □Extremitynumbness□Fever □Polyuria(excessiveurination) □Extremityweakness□Malaise(outofsorts) □Urinaryfrequency □Gaitdisturbance□Nightsweats □Urinaryincontinence □Headache□Weightgain □Urinaryretention □Memoryloss□Weightloss □Other:_______________ □Seizures□Other:_______________ □Tremors Reproductive-FEMALE □Other:_______________HEENT □AbnormalPap□Eardischarge □Dysmenorrhea(painfulperiods) Psychiatric□Earpain □Dyspareunia(painfulintercourse) □Anxiety□Eyedischarge □Hotflashes □Depression□Eyepain □Irregularmenses □Insomnia□Hearingloss □Vaginaldischarge □Other:_______________□Nasaldischarge □Other:_______________ □Sinuspressure Metabolic/Endocrine□Sorethroat Genitourinary-MALE □Coldintolerance□Visualchanges □Dribbling □Heatintolerance□Other:_______________ □Dysuria(painfulurination) □Polydipsia(excessivethirst) □Hematuria(bloodyurine) □Polyphagia(excessivehunger)Respiratory □Polyuria(excessiveurination) □Other:_______________□Chroniccough □Slowstream□Cough □Urinaryfrequency Musculoskeletal□KnownTBexposure □Urinaryincontinence □Backpain□Shortnessofbreath □Urinaryretention □Jointpain□Wheezing □Other:_______________ □Jointswelling□Other:_______________ □Muscleweakness Reproductive-MALE □NeckpainCardiovascular □Erectiledysfunction □Other:_______________□Chestpain □Peniledischarge□Claudication(legcramping) □Sexualdysfunction Hematologic/Lymphatic□Edema(swelling) □Other:_______________ □Easybleeding□Palpitations □Easybruising□Other:_______________ Integumentary □Lymphadenopathy □Breastdischarge □Other:_______________Gastrointestinal □Breastlump□Abdominalpain □Brittlehair Immunologic□Bloodinstools □Brittlenails □Contactallergy□Changeinstools □Hairloss □Environmentalallergies□Constipation □Hirsutism(malepatternhairinwomen) □Foodallergies□Diarrhea □Hives □Seasonalallergies□Heartburn □Pruritis(itching) □Other:_______________□Lossofappetite □Molechanges□Nausea □Rash□Vomiting □Skinlesion□Other:_______________ □Other:_______________

(enlargedlymphnodes)

Page7

Revised 2/28/18

PatientName:_____________________________________________________________________________

PREVIOUSSURGERIES-Pleasebeasspecificaspossible:Surgery Date Location/Physician

MEDICALHISTORY-Pleasebeasspecificaspossible:Condition Management TreatmentOutcome

FAMILYHISTORY-! Isyourmotherliving:□Yes□No IfYes,Age:_______________IfNo,Ageatdeath:_______________

Listallmedicalproblems:______________________________________________________________

! Isyourfatherliving:□Yes□No IfYes,Age:_______________IfNo,Ageatdeath:_______________

Listallmedicalproblems:______________________________________________________________

! Siblings: □Brother□SisterLiving:□Yes□No

IfYes,Age:_______________IfNo,Ageatdeath:_______________Listallmedicalproblems:________________________________________________________

□Brother□SisterLiving:□Yes□NoIfYes,Age:_______________IfNo,Ageatdeath:_______________Listallmedicalproblems:________________________________________________________

□Brother□SisterLiving:□Yes□NoIfYes,Age:_______________IfNo,Ageatdeath:_______________Listallmedicalproblems:________________________________________________________

Page8

Revised 2/28/18

PatientName:_____________________________________________________________________________

SOCIAL-! Haveyouhadanyrecentsocialchanges(marriage,divorce,employment,etc.):□Yes□No

IfYes,describe:______________________________________________________________________

! Areyoumarried:□Yes□NoIfYes,HowLong:_______________Nameofspouse:______________________________________

! Isyourspousedeceased:□Yes□NoIfYes,When:__________/__________/__________

! Haveyoubeendivorced:□Yes□NoIfYes,Howmanytimes:_______________

! Areyoucurrentlyemployed:□Yes□No IfYes,Howlong:_______________ Occupation:__________________________________! Areyoureceivingdisability:□Yes□No

! Isthispainbeingtreatedbyaworkerscompensationclaim:□Yes□No

! Haveyoutakenanylegalactioninregardstoyourpain:□Yes□No

! Haveyoueverbeenabused:□Yes□NoIfYes,□Physical□Sexual□Emotional

HABITS-! Doyousmoke:□Yes□No □Quit When:__________/__________/__________

IfYes,Packsperday:_______________Years:_______________

! Doyousmokeapipe:□Yes□No□Quit When:__________/__________/__________IfYes,Howmuch:_______________Years:_______________

! Doyouchewtobacco:□Yes□No□Quit When:__________/__________/__________IfYes,Howmuch:_______________Years:_______________

! Doyoudrinkalcohol:□Yes□No□QuitWhen:__________/__________/__________IfYes,Howmuch:_______________Years:_______________

! Doyouuseillegaldrugs:□Yes□No□Quit When:__________/__________/__________IfYes,Howmuch:_______________Years:_______________Whattypes:____________________________________________________________________

! Doyouconsumecaffeine:□Yes□NoIfYes,

□Coffee _______________cups/day□Tea _______________cups/day□Soda _______________cups/day□EnergyDrinks_______________cups/day

Page9