FIRST NAME:
MI:
LASTNAME:
QME / AME INFORMATION QUESTIONNAIRE
Wayne E. Anderson, D.O.
A Medical Corporation
Chronic Intractable Pain Disorders
Headache & Facial Pain Disorders
Neurotoxin Therapy
You have an upcoming QME/AME appointment. During this appointment, we
will discuss the history and impact of your injury. We then will perform a
physical examination. Please note that the QME/AME appointment does not
establish a physician–patient relationship and that no medical advice or
prescriptions are provided.
After your appointment, we will combine your medical records and the
information you have provided to us and issue a report. In order for the report
to be as accurate as possible, it is important that you complete this information
to the best of your ability. This information must be completed before the
appointment.
Date of Birth:
Date of Appointment:
Board Certified Neurology
American Board of Psychiatry & Neurology
Board Certified Pain Medicine
American Board of Psychiatry & Neurology
in association with the
American Board of Anesthesiology
Subspecialty Certified Headache Medicine
United Council for Neurological
Subspecialties
Qualified Medical Evaluator
Member of the
California Pacific Neuroscience Institute
Date of Injury:
Sex: Male / Female
THE PROBLEM
Where on the body is the problem? Please include right or left, front or back.
When did the problem begin?
How did it begin? (Accident, injury, unknown, etc.)
If an accident or injury, please describe how the accident or injury happened:
Correspondence to:
45 Castro Street Suite 225
San Francisco CA 94114
415.558.8584 tel
415.513.4521 fax
www.wayneanderson.net
How often does it occur?
CONSTANT/INTERMITTENT/EPISODES
If in episodes, how often?
DAILY / WEEKLY / MONTHLY / OTHER:
If in episodes, how long last?
SECONDS/MINUTES/HOURS/DAYS/CONSTANT
Progression of problem:
STAYING SAME / GETTING BETTER / GETTING WORSE?
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What makes it worse:
UNKNOWN / STRESS / INCREASED ACTIVITY / OTHER:
What makes it better:
UNKNOWN / MEDS / REST / ICE / HEAT / OTHER:
Please circle any words or phrases below that you associate with this problem. Not all persons will have these problems.
WORSE WITH ACTIVITY/AVOID LOUD NOISES/AVOID BRIGHT LIGHTS/NAUSEA/VOMITING/SEEING FLASHING LIGHTS/NIGHTTIME/
TIGHT BAND/PULSATING/SPEECH PROBLEM / DIZZINESS /CHILLS/WAKES ME UP / SEX / ORGASM / MENSTRUAL RELATED/FEVER/
TEARING OR NOSE RUNNING/EYEBALL PAIN/ DOUBLE VISION / DEAFNESS / RINGING IN EARS /CAN’T WALK PROPERLY/CONFUSION/
PASSING OUT/BLINDNESS/TRUE WEAKNESS OR PARALYSIS/ FEELING OF WEAKNESS / NUMBNESS OR TINGLING IN ANY PART(S) OF THE BODY/
THIS PROBLEM RUNS IN THE FAMILY / PRIOR HEAD INJURY / PRIOR BRAIN PROBLEM
Please circle any things below that you have done to diagnose or treat this problem.
EMG / NCV / MRI / CT / XRAY / SPINAL TAP / EEG / OTHER DIAGNOSTIC TESTS:
SURGERY / FACET INJECTIONS/EPIDURAL INJECTIONS/TRIGGER POINT INJ/BOTOX / SPINAL CORD STIMULATOR/TENS UNIT / MEDICATION /
MEDITATION / YOGA / GYM/ HOME EXERCISE/ACUPUNCTURE/PSYCHOLOGY/CHIROPRACTIC/OSTEOPATHIC MANUAL TREATMENT/OTHER:
Please tell us how severe your problem is, where 10 is the most severe anything could be:
How severe is the problem in general?
0 1 2 3 4 5 6 7 8 9 10
MILD (HATE IT BUT CAN KEEP DOING THINGS) /
MODERATE (SLOWS DOWN THINGS I TRY TO DO) /
SEVERE (RESTRICTS MANY THINGS I TRY TO DO) /
VERY SEVERE (HAVE TO STOP EVERYTHING ELSE)
MEDICAL HISTORY
Current medical conditions for which you are currently being treated or monitored:
Past medical conditions (major things you had in the past but no longer have):
Surgeries (please include the approximate year of surgery):
Family history (please include things that run in the family if they are related to the injury):
Social history:
Alcohol PLEASE LIST YOUR ALCOHOL USE:
Illicit drugs YES / NO?
Smoking CURRENT / FORMER / NEVER?
Abuse PHYSICAL ABUSE IN PAST / PHYSICAL ABUSE CURRENTLY (THIS IS A PAIN RISK FACTOR)
Home ABLE TO TAKE CARE OF SELF-CARE / HAVE CARE GIVER / OTHER:
Please do not write below this line. Please do not write below this line. Please do not write below this line.
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Review of systems: THIS IS A LIST OF YOUR POSSIBLE CURRENT SYMPTOMS AT THIS EXACT TIME, NOT A LIST OF
CONDITIONS THAT YOU MAY HAVE. For example, if you have asthma, you would list ASTHMA above under current
medical conditions. If you are not having asthma problems today, you would not circle “wheezing” on the list below.
But, if you ARE wheezing today, you would circle “wheezing” on the list below. Please circle any conditions that you
are experiencing currently:
ENERGY / SWEATING / BLEEDING / WEIGHT CHANGES / WORST HEADACHE OF LIFE / SINUS / STIFF
PAIN (WHERE:
)
NECK / MUSCLE SPASM / DOUBLE VISION / SENSITIVE TO LIGHT / VISION PROBLEMS / EYELID DROOP
DISCHARGE (WHERE:
)
/ HEARING PROBLEMS / RINGING / HOARSENESS / CHOKING / CAN’T SWALLOW / DENTAL ISSUE /
BAD TASTE / CAN’T TALK PROPERLY / WRONG HEARTBEAT / CONGESTED / SHORT OF BREATH /
LUMPS (WHERE:
)
COUGHING / WHEEZING / APPETITE PROBLEM / DIFFICULTY SWALLOWING / HEARTBURN / NAUSEA /
LESIONS (WHERE:
)
DIARRHEA / CONSTIPATION / CAN’T CONTROL BOWELS-INCONTINENT / BLOOD / ABNORMAL URINE
SORES (WHERE:
)
/ CAN’T CONTROL URINE / PREGNANT / TRYING TO BECOME PREGNANT /WATER INTAKE /
SWEATING / HOT FLASHES / FEEL WEAK / SEXUAL DIFFICULTY / BRUISING / STIFFNESS IN BODY PART
SWELLING (WHERE:
)
/ CLICKING JOINT / GRINDING JOINT / CRAMPS / MUSCLES SHRINKING / DIZZY / FAINTING /
BLEEDING (WHERE:
)
CONCENTRATION / MEMORY LOSS / CONVULSIONS / ABILITY TO SMELL / ABILITY TO TASTE /
BALANCE / COORDINATION / NEW OR UNEXPLAINED WEAKNESS / NEW OR UNEXPLAINED SENSORY
LOSS / MOOD / SLEEP / BAD THOUGHTS / DANGEROUS THOUGHTS /SKIN SENSITIVITY / FINGERNAIL
OR HAIR ISSUES / OTHER:
MEDICATION HISTORY
Allergies: Please list any medications or substances you are either allergic to or cannot tolerate. Please also list the
reason why you cannot use the medication:
Current medications: Please list your current prescription medications, over the counter medications, and supplements.
You may attach a list if you like, but the list must include all six (6) columns listed below.
Medication
Size
How taken
Example: Aspirin
81mg
1 pill daily
Example: Vicodin
5/500
1 every 4 hrs if needed
If as needed, total in a day
Average 3 per day
Purpose
Prescriber
Prevent heart attack
Dr. John Doe
Knee pain
Dr. Jane Doe
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Past medications: Although it may be difficult to remember things that you have tried for this condition, it is important
that you do your best. Knowing what was tried and why it is no longer used can be helpful to determine what types of
medications are appropriate and, obviously, to avoid retrying something that caused problems.
Prior medication
How long taken
Why no longer used
Example: aspirin 81mg
Every day for 3 years
Caused stomach bleeding
STANDARDIZED QUESTIONNAIRES
Please read this carefully. The following questionnaires are not written by us. They are standard questionnaires used to
help validate your condition and your responses are especially important in work comp cases and legal cases. The
questionnaires are not valid if you skip or change any questions. Therefore, please answer each question to the best of
your ability, choosing the closest answer if there is no exact answer. Please note that you might not need to answer each
questionnaire (see the top of each questionnaire).
CHRONIC PAIN CLAIMS ONLY: PLEASE COMPLETE THE FOLLOWING SECTION
Please circle a number for each of the pain words below. 0=don’t have it, 1=some, 2=more, 3=describes my pain a lot:
0123 Gnawing
0123 Splitting
0123 Burning
0123 Frightening
0123 Tender
0123 Throbbing
0123 Shooting
0123 Tiring
0123 Stabbing
0123 Cramping
0123 Heavy
0123 Cruel
0123 Aching
0123 Sharp
0123 Sickening
HEADACHE CLAIMS ONLY: PLEASE COMPLETE THE FOLLOWING SECTION
On how many days in the last 3 months did you miss work or school because of your
headaches? (IF YOU DO NOT WORK OR GO TO SCHOOL, THE ANSWER IS ZERO)
How many days in the last 3 months was your productivity at work or school reduced by
half or more because of your headaches? (DO NOT INCLUDE DAYS COUNTED IN QUESTION 1.)
On how many days in the last 3 months did you not do household work (such as housework,
home maintenance, shopping, caring for children and relatives) because of your
headaches?
How many days in the last 3 months was your productivity in household work reduced by
half of more because of your headaches? (DO NOT INCLUDE DAYS COUNTED IN QUESTION 3.)
On how many days in the last 3 months did you miss family, social or leisure activities
because of your headaches?
TOTAL OF NUMBERS:
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ALL QME/AME CASES: PLEASE COMPLETE THE FOLLOWING SECTION
For each question below, please choose a number from zero to ten (0-10) to let us know how much the pain affects your
ability. For convenience, we have provided examples of what a ten would represent.
Does your pain …
Example of ten (10)
…interfere with your normal work inside and outside the home?
0 1 2 3 4 5 6 7 8 9 10
Can’t work at all
…interfere with personal care?
0 1 2 3 4 5 6 7 8 9 10
Need help with bathroom
…interfere with traveling?
0 1 2 3 4 5 6 7 8 9 10
See doctors only
…affect your ability to sit or stand?
0 1 2 3 4 5 6 7 8 9 10
Lay down always
…affect your ability to lift objects off the floor, bend, stoop, or squat?
0 1 2 3 4 5 6 7 8 9 10
Cannot do at all, ever
…affect your ability to lift overhead, grasp objects, or reach for
things?
0 1 2 3 4 5 6 7 8 9 10
…affect your ability to walk or run?
0 1 2 3 4 5 6 7 8 9 10
In wheelchair only, can
never walk or run
…force you to see doctors much more than before your pain began?
0 1 2 3 4 5 6 7 8 9 10
See doctors every week
…interfere with your ability to see the people who are important to
you as much as you would like?
0 1 2 3 4 5 6 7 8 9 10
Never see people who are
important to me
0 1 2 3 4 5 6 7 8 9 10
Can’t do any activities that
are fun, ever
0 1 2 3 4 5 6 7 8 9 10
Lost ALL income
0 1 2 3 4 5 6 7 8 9 10
Every day
0 1 2 3 4 5 6 7 8 9 10
Need help with most
everything all the time
0 1 2 3 4 5 6 7 8 9 10
Severe depression
0 1 2 3 4 5 6 7 8 9 10
Severe emotional
problems
…interfere with recreational activities and hobbies that are important
to you?
Has your income declined since your pain began (because of the
pain)?
Do you choose to take pain medication every day to control your
pain?
Do you need the help of your family and friends to complete
everyday tasks because of your pain?
Do you now feel more depressed, tense, or anxious than before your
pain began?
Do the emotional problems caused by your pain interfere with your
family, social or work activities?
Cannot do at all, ever
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ALL QME/AME CASES: PLEASE COMPLETE THE FOLLOWING SECTION
For each of the ten (10) lines below, please circle the one (1) phrase that best describes your situation. It is understood
that your situation may not be exactly like the phrases below, but please choose the one phrase in each line that is the
closest to your exact situation. Please do not change any questions or skip any questions or the questionnaire will not be
valid.
1
2
3
4
5
6
7
8
9
10
I can tolerate the
pain without using
pain killers
I can look after
myself normally
without extra pain
I can lift heavy
weights without
extra pain
Pain does not
prevent me
walking
I can sit in any
chair as long as I
like
I can stand as long
as I want
Pain does not
prevent me from
sleeping well
My sex life is
normal with no
extra pain
My social life is
normal and gives
me no extra pain
I can travel
anywhere
PAIN IS BAD BUT I
MANAGE WITHOUT
PAIN KILLERS
I CAN LOOK AFTER
MYSELF NORMALLY
BUT IT CAUSES
EXTRA PAIN
I CAN LIFT HEAVY
WEIGHTS BUT IT
GIVES EXTRA PAIN
PAIN PREVENTS
WALKING MORE
THAN 1 MILE
I CAN SIT IN A
SPECIAL CHAIR AS
LONG AS I LIKE
I STAND AS LONG AS
I WANT BUT WITH
EXTRA PAIN
I CAN SLEEP WELL
ONLY BY TAKING
PILLS
MY SEX LIFE IS
NORMAL BUT
CAUSES EXTRA PAIN
MY SOCIAL LIFE IS
NORMAL BUT
CAUSES EXTRA PAIN
I CAN TRAVEL
Pain killers give
complete relief
from pain
It is painful to look
after myself and I
am slow and
careful
I can manage heavy
weights if
conveniently
positioned
Pain prevents me
walking more than
0.5 miles
Pain prevents me
sitting more than 1
hour
Pain prevents
standing for more
than 1 hour
Even with pills I
have less than 6
hours sleep
Sex life nearly
normal but is very
painful
Pain limits some
activities such as
dancing
PAIN KILLERS GIVE
MODERATE RELIEF
FROM PAIN
I NEED SOME HELP
BUT MANAGE MOST
OF MY PERSONAL
CARE
LIGHT OR MEDIUM
WEIGHTS IF
CONVENIENTLY
POSITIONED
PAIN PREVENTS ME
WALKING MORE THAN
0.25 MILES
PAIN PREVENTS ME
FROM SITTING MORE
THAN 0.5 HOURS
PAIN PREVENTS
STANDING FOR MORE
THAN 30MIN
EVEN WITH PILLS I
HAVE LESS THAN 4
HOURS SLEEP
SEX LIFE IS SEVERELY
RESTRICTED BY PAIN
PAIN KEEPS ME FROM
GOING OUT AS OFTEN
WITH EXTRA PAIN
Pain is bad but I
manage journeys
over 2 hours
I ONLY DO TRIPS OF
LESS THAN 1 HOUR
i
ii
iii
ANYWHERE BUT
Pain killers give
very little relief
from pain
I need help
every day in
most aspects of
self-care
I can lift only
very light
weights
I can only walk
using a stick or
crutches
Pain prevents
sitting more
than 10 minutes
Can’t stand for
more than 10
min
Even with pills I
have less than 2
hours of sleep
Sex life is nearly
absent because
of pain
Pain has
restricted me to
my home
I only do
necessary trips
under 30
minutes
Pain killers have no
effect on the pain
I do not get dressed
wash with difficulty
and stay in bed
I cannot lift or carry
anything at all
I am in bed most of
the time and crawl
to the toilet
Pain prevents me
from sitting at all
Pain prevents me
from standing at all
Pain prevents me
from sleeping at all
Pain prevents any
sex life at all
I have no social life
at all because of
pain
Pain prevents me
from traveling
except to the doctor
iv
End of questionnaires.
Thank you.
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