Microsoft word - revised - new patient 2112005.doc

DATE: ________________
Please read these sheets carefully and answer ALL QUESTIONS to the best of your ability. They will
assist us in better treating your pain. Thank you for your time and cooperation.
NAME:

WHERE IS MOST OF YOUR PAIN TODAY / WHY ARE YOU COMING TO OUR
OFFICE, TODAY? (We realize that many of our patients may have multiple sites of pain, or are being
referred for one particular type of pain. Therefore, in order to better serve you, and to try and provide you
with the best results possible, we can only concentrate on one area at a time before moving to other
areas of your body). Please indicate on the diagram below using the symbols to describe the type of pain
to that area. Mark the area to where the pain radiates, with using arrows. More than one type of symbol
may be necessary—we understand that this may be the case.
ACHING
NUMBNESS
PINS & NEEDLES
STABBING
DURATION
How long have you had this pain? What was the date of your injury? What do you believe is the cause of your pain? Is it constant or does the pain come-and-go
AGRAVATING/ALLEVIATING FACTORS
Please (√) indicate if the following increases or decreases your pain. INCREASES
DECREASES
DAILY FUNCTIONING
Circle the numbers below that best describe how pain has interfered with your daily functioning.
(0=Does not interfere, 10=Interferes greatly)
PAIN SCALE
Use the following rating scales to indicate how severe your pain is. Circle the appropriate
number with 1 being least and 10 being the worst. There is no pain greater than 10.
Remember, 10 is the most severe pain possible. (For example, being on fire, while completely
awake).
Your pain at its WORST:
Your pain at its LEAST severe:
Your pain on AVERAGE:
Your pain at the PRESENT TIME:
What level of pain do you think you could PRIOR TREATMENTS
Please check any of the following treatments you have had for this pain problem. Include any
dates and results. (√) Check all that apply.

ALLERGIES
Do you have any allergies to any medications? If so, please list which ones and the exact type
of reaction you have.
Do you have any allergies to any foods, including shellfish or strawberries?
Are you allergic to Latex, iodine, or IVP dye?
SURGERY
Please list all surgeries you have had and the year.
SURGERY
Please list any MEDICAL CONDITIONS you currently have and any illnesses or conditions for
which you have been hospitalized. (i.e. osteoarthritis, hypertension, colitis, bipolar disorder,
heart attack, seizure, asthma, etc.)
Please answer ALL of the following questions. If the item does not apply to you, then mark it
NO. We try to take the entire person into consideration, when treating pain—this includes
treating the psychological aspect of pain. In order for us to adequately address this area and
the needs of these patients, it is necessary for us to have a basic, beginning amount of
information on everyone. Please answer truthfully and completely. Omissions and untruthful
responses don’t allow us to offer you all benefits one might need for proper healing.

ALCOHOL USE
How much beer/alcoholic beverages do you drink?
Daily? ___________ Weekly? ___________ Monthly? ___________
I drink:
very infrequently (less than monthly) do not drink
ALTERNATIVE MEDICINE
What treatments have you sought to help with pain:
Are the treatments still ongoing? YES NO
AUTOMOBILE TYPE
Do you drive? YES NO
What type of automobile do you drive? AUTOMATIC OR MANUAL
If NO, what is the reason for not driving? _____________________________________
CAFFEINE USE
How many caffeinated beverages do you drink per day?

EDUCATION LEVEL
What level of education do you have?

EMPLOYMENT
Are you currently employed? YES NO
Occupation / Reason for Non-employment______________________________________

ILLEGAL DRUG USE
Do you use or have you ever used illegal drugs:
If yes, which drugs do you currently use? ___________________________________ Are you currently in/have you ever attended a substance abuse program? YES NO LITIGATION
Is your pain the result of an accident or injury?
Is there a history of litigation in the past? Who is your attorney? _________________________________________
MARITAL STATUS

CHILDREN
How many children do you have? _________
MENTAL HEALTH HISTORY
Have you sought substance abuse treatment in the past?
Have you ever attempted suicide in the past? Have you been hospitalized for any other psychiatric illness? YES NO If you answered YES to any of these questions, please explain below:
PRESCRIPTION DRUG ABUSE
Have you ever been found abusing prescription medications, such as amphetamines,
benzodiazepines, barbiturates, codeine, Demerol, or morphine? YES NO
SLEEP HABITS
Do you sleep on a:
Do you have difficulty falling asleep? YES NO
Do you have difficulty staying asleep? YES NO
Do you require medication to fall asleep? YES NO If yes, what:_________________
Do wake in the morning feeling rested or still feeling tired? (Check one)
Does the pain interrupt your sleep? YES NO
If yes, how many time(s) does it awaken you? 1 2 3
TOBACCO USE
Do you smoke? YES NO
If yes, how many packs a day do you smoke?
PLEASE CHECK THE BOX NEXT TO THE CONDITIONS, WHICH YOU HAVE EVER EXPERIENCED.
Indicate which of the following medications you have taken in the past for you pain. If a particular
medication is not found in the table, write it on the lines provided at the end of this sheet.
Narcotics / Opioids
Steroid Therapy
Pain Relief Adjuncts / Sleep
Aids / Anti-depressants
Anti-anxiety Medications
Sleep Aids
Muscle Relaxants /
Antispasmodics
Pain Relief Adjunct / Anti-
convulsant Medications
Topical Agents
Migraine Medications
Natural Medicines
Non-steroidal/Anti-
Inflammatory Agents

Source: http://www.sipain.net/images/newPatientQuestionnaire.pdf