What is your age

NEW PATIENT PAIN/SPINE INTAKE FORM
Referring Physician:
Date of Birth:
Primary Care Physician:
Are you right or left handed?
What is the main problem that brings you here today (you may check more than one)?
Which area of pain is the worst?
On the drawings below, please shade the area where you currently experience pain.
PAIN HISTORY
When did the pain start (month/day/year)?
How did the pain start?

Have you ever been involved in any legal proceedings related to this health matter?

Do you have any other legal issues?
Have you had any previous major pain issues?
What is the quality of your pain/symptoms?
Since the pain/condition began has it:

On a scale from 0 to 10 (where 10 is the worst possible pain) how would you describe the intensity of
your pain:
Average level of pain over the last month: Current level of pain:
At your worst, what is your pain level: At your best your pain is:
Do you have any of the following associated symptoms?

RELIEVING AND AGGRAVATING FACTORS
Check off the following boxes depending on how the position affects your pain:
Decrease Increase No Change
OTHER THERAPIES FOR PAIN
Please check all of the treatment you have tried for this pain condition and indicate whether the
treatment provided you with any relief.
Treatment
No Relief
Moderate Relief
Excellent Relief

MEDICATIONS YOU HAVE TAKEN IN THE PAST FOR PAIN OR MOOD
Using the list below, please indicate the prescription medication(s) that you have tried in the past. If you
have not taken these medications, you can skip this section.
Opioids
Antiinflammatories (NSAIDs)
Muscle Relaxants
Antidepressants
Antianxiety Agents
Other Agents
ALLERGIES
Are you allergic to latex?
Are you allergic to IV Contrast?
Do you have any other allergies?

MEDICAL HISTORY
Current/Past medical problems:
Other Conditions:
1.
Prior spine surgeries:
Prior major surgerie not spine related:
1.
All Current Medications & Supplements/Herbs (name, dose, frequency)
1.
Do any of your family members (blood relatives) have any of these diseases?

Marital status:
Have you experienced significant stress in the past year?
What is your living situation?(family, friends alone, etc.)
If you have children, what are their ages?
What is your current work status?
What is the highest grade you completed or degree you received?

Tobacco Use
Alcohol Use
Other Drug Use
Caffeinated Drinks
REVIEW OF SYMPTOMS (Please mark all of the following that apply to you)

Source: http://assets.harvardvanguard.org/app_assets/pain-management-intake-form_20130809t075446_en_9d4637bd-b1f8-465b-86da-476f6140689c.pdf