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Physicians
James Johnson, DO
Richard Morgan, MD
Wayne Brown, MD
Treatment Options
Epidural Steroid / Nerve Block
Physical Therapy and Exercise
Medication Management
Pain Management Counseling
Palliative Care Consultation
Spinal Cord Stimulation
Intrathecal Pump Therapy
Kyphoplasty
Blog
SJ Pain Physician Patient Questionnaire
PERSONAL
Full Name
*
Email
*
Current Marital Status:
*
Single
Married
Divorced
Widowed
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
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
MEDICAL HISTORY
8. Are you allergic to any medications?
Yes
No
If so, list:
9. Do you smoke?
Yes
No
If yes, number of packs per day:
10. Do you drink alcoholic beverages?
Yes
No
How may drinks per day:
or per week:
Height
Weight
11. Have you ever had any of the following? (check all that apply)
Rheumatic Fever
Lung Disease
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
12. Have you had any surgeries?
Yes
No
Please list all operations and approximate dates:
WORK HISTORY
13. What is your occupation?
14. Are you working now?
Yes
No
15. If not currently working, how long have you been off work?
16. Are you currently receiving Workers’ Compensation (disability income)?
Yes
No
17. Are you currently in the process of trying to obtain compensation (disability benefits)?
Yes
No
18. Are you involved in any litigation (are you suing anyone) related to your pain?
Yes
No
19. Have you had to be off work for pain problems in the past?
Yes
No
If yes, for how long?
PAIN IMPACT SCORE
20. 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:
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