* Denotes Required Field.
PAIN HISTORY
1. When did your present episode of pain begin?
2. Describe the pain in your own words.
3. What makes it worse ?
4. What makes it better?
PAIN DESCRIPTION
5. Check to describe the pattern of your pain.Continuous Steady Constant Rhythmic Periodic Intermittent Brief Momentary Transient
6. Check which best describes the type of pain.Burning Shooting Cramping Aching Crushing Pulling Gnawing Throbbing Pounding Sharp Stabbing Tender
7. On a scale of 0-10, 0 represents no pain and 10 the very worst…… How would you score your pain today? 0 1 2 3 4 5 6 7 8 9 10 What is your daily average pain? 0 1 2 3 4 5 6 7 8 9 10 How would you score your worst pain from this injury? 0 1 2 3 4 5 6 7 8 9 10
8. Please mark the areas on your body where you feel the described sensations: This will be completed when you arrive.
9. Are you allergic to any medications? Yes No If so, list:
10. Do you smoke? Yes No If yes, number of packs per day:
11. Do you drink alcoholic beverages? Yes No How may drinks per day: , or per week
MEDICAL HISTORY
Height: Weight:
12. Have you ever had any of the following? (check all that apply) Rheumatic Fever Lung Disease Measles Scarlet Fever Heart Disease Mumps Diabetes Liver Disease Chicken Pox Epilepsy, Seizures Hepatitis Ulcers Hemophilia Gallbladder Disease Stroke Bleeding Tendencies Kidney Disease Cancer Blood Disease Thyroid Disease Anemia Colon Problems Asthma Stomach Problems Tuberculosis Emotional Problems High Blood Pressure Joint Disease/Arthritis
13. Have you had any surgeries?Yes No
Please list operations and approximate dates:
WORK HISTORY
14. What is your occupation?
15. Are you working now? Yes No
16. If not currently working, how long have you been off work?
17. Are you currently receiving Workers’ Compensation (disability income)? Yes No
18. Are you currently in the process of trying to obtain compensation (disability benefits)? Yes No
19. Are you involved in any litigation (are you suing anyone) related to your pain? Yes No
20. Have you had to be off work for pain problems in the past? Yes No For how long?
PAIN IMPACT SCORE
21. Click the one number that describes how, during the past 24 hours, pain has interfered with your:"0" = Does Not Interfere "10" = Completely Interferes A. General Activity 0 1 2 3 4 5 6 7 8 9 10 B. Mood 0 1 2 3 4 5 6 7 8 9 10 C. Walking ability 0 1 2 3 4 5 6 7 8 9 10 D. Normal work (includes both work outside the home and housework) 0 1 2 3 4 5 6 7 8 9 10 E. Relations with other people 0 1 2 3 4 5 6 7 8 9 10 F. Sleep 0 1 2 3 4 5 6 7 8 9 10 G. Enjoyment of life 0 1 2 3 4 5 6 7 8 9 10
SCORE:
Your Email (required)
8/09 #623650
