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Pain management center

PAIN MANAGEMENT CENTER
PATIENT HISTORY
NAME: _______________________________________________________________ Please fill in completely (0) all circles (yes and no) as pertaining to your current symptoms.
Constitutional
Musculoskeletal
Ophthalmology
Neurology
Dermatology
Endocrinology
Cardiology
Hematology/Lymph
Respiratory
Allergy/Immune system
Gastroenterology
Psychology
Male reproductive
Female reproductive
How long have you had your pain? O 0-6 months O 6-12 months O 1-5 years O 5-10 years O longer than 10 years In the last 2-3 weeks when does your pain occur? On a scale of 0 to 10, with 10 being the worst pain, mark where the severity of your pain is. O 0 Associated numbness O Yes O No Associated Tingling O Yes O No What was the setting when the problem first occured? O prolonged keyboard activity O repetitive grasping O sports (without obvious trauma) O squatting Please describe your pain (quality): O aching O penetrating O pins and needles O pressure Please indicate those activities that INCREASE your pain: (check all that apply) O work O foods or beverages O locale (i.e. home/work/etc.) O medications O menstrual cycle O physical activites O recreational drug use O sleep-related factors Please indicate those activities that DECREASE your pain: (check all that apply) O walking O emergency room treatment O elevating the affected area O non weight bearing O supporting the extremity O avoiding stress O language difficulty O mental status change How many ER visits have you had in the last 3 months for pain? Do you take any of the following anticoagulants? (check all that apply) Have you tried any of these therapies: O acupressure O nerve stimulation O occupational therapy Have you tried any of these pain clinic treatments: O injection therapy O medications O physical therapy Have you tried the following NSAIDS to help relieve your pain: O ibuprofen O aleve
Are you on Workers Comp?

Mark the appropriate information related to Worker's Compensation:
O unable to work at all since the injury O able to work with restrictions since the injury O temporary limitations after the injury
Litigation pending:
O Yes

If you are involved in any lawsuits, who is the lawsuit against? (Check all that apply)
O Worker's Compensation O Auto accident

Have you been to any of the following types of doctors?
O Back Surgeon

Past Medical History
Heart disease
Thyroid/endocrine problem O Yes O No
Family History
Is your father still alive?
Do you have children or other dependents at home? O Yes O No
Social History
What is your marital status?

Are you currently employed?
Are you on Disability?
What type of disability do you have?

Do you use alcohol to control your pain?
O Yes O No

Mark if you use any of the following drugs recreationally
:
O Amphetamines

Dependency or addiction to drugs now or in the past? (Check all that apply)
O Amphetamines
O Marijuana O Morphine O Oxycodone O Soma Please mark your pain area(s) on this diagram.

Source: http://www.utahpaincenter.com/binary/org/SJM_PSP_85/doc/Patient%20History%20Bubble%20Form.pdf

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