Pain consult

MEDICAL HISTORY INFORMATION


1) PATIENT INFORMATION:
TODAY’S DATE

NAME_________________________________________BIRTHDATE:____________________________
ADDRESS: _____________________________________CITY:___________________________________
PROV/POSTAL CODE_____________________________PH:________________WK:________________
EMAIL____________________________________PAYMENT: PLEASE NOTE C CARD # BELOW:
________________________________________________EXP DATE: _____________________________
GENDER: MALE FEMALE
HEIGHT: ______________ WEIGHT: ________________________
2) LIFESTYLE INFORMATION:

TOBACCO (smoke, chew, dip) ______________________ __________________________
ALCOHOL (beer, wine, hard liquor) ____________________ __________________________
CAFFEINE (colas, coffee, tea) ________________________ ___________________________
IMPAIRMENTS: Check if you have any of the following:
Physical Impairment ____________ Visual Impairment ______________ Hearing Impairment __________
EXERCISE: Do you exercise regularly? ___Y ____N If Yes: Please note exercise & how often:
STRESS MANAGEMENT: Do you practice stress management techniques? ___Y ____N If Yes, pls describe:
DIET: Describe your typical daily food intake:
Breakfast:
Lunch:
Supper:
Any Snacks/other:
3) DOCTOR INFORMATION: Please list each Dr. from whom you seek care with address & phone number.
4) ALLERGIES: please check all that apply: ___None Known
__penicillin

__codeine

Note allergic reaction: ________________________________________________________________
___________________________________________________________________________________
5) OVER THE COUNTER (OTC) ISSUES: Please check all products used regular or occasionally.
__pain reliever

__ibuprofen (eg. Motrin)

__other: ___________________________________
__Nutritional/Natural Supplements: Pls identify and list products you are using:
-herbs, vitamins, minerals, supplements, enzymes, others
6) MEDICAL CONDITIONS/DISEASES. Please check all that apply to you.

__heart disease
__other: _______________________________________________________________________________
7) PRESCRIPTION MEDICATION: List all prescription medication you are using (include physician samples)
____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ NAME__________________________________________________________DATE_________________ Circle the number that best describes your pain, 0 is NO PAIN and 10 is WORST IMAGINABLE PAIN. Circle the number that best describes your pain at its worst during the last month. Circle the number that best describes your pain at its least during the last month. Circle the number that best describes your pain on average during the last month. Circle the number that best describes your pain as it is right now.

Source: http://www.compoundingpharmacy.sk.ca/pdfs/pain_consult.pdf