ADVANCED INTERVENTIONAL PAIN CONSULTANTS
Name _______________________________
Age _____
Follow Up Consultation
Date of Birth _____________ Date ________________
REFERRING PHYSICIAN ___________________________ PRIMARY CARE DOCTOR _____________________________
What is your main pain complaint?
Low-back
Mid-back
Neck
Head
Joints Hip Knee Shoulder Muscles
HISTORY OF PRESENT ILLNESS
Any changes since your last visit ______________________________________________________________________
Where is your pain located?
How intense is your pain? Circle lowest and highest level
If you are being treated for headaches, how many headaches do you get per week? _____ How many per month? _____
How do you best describe your pain?
What is the pattern of your pain?
Any associated symptoms?
Does the pain radiate to other areas?
Dull
Sharp Stabbing Aching Electrical Burning Shock Throb
Constant Intermittent Mornings Afternoons Nights
___ Numbness ___ Tingling ___ Weakness ___ Muscle spasms
No
Yes, where does the pain radiate? _____________________________
List all medications we prescribe for pain? Include dosages and how many times
__________________________________________________________________________________________________
__________________________________________________________________________________________________
None
How much pain relief do you obtain with these medication?
10%
20%
30%
40%
50%
60%
70%
80%
Are you taking your medications as we prescribe them?
Have you INCREASED the dose of medications prescribed by yourself or called for early refills?
Are you taking pain medications from a different doctor?
Nausea
90%
100%
___ Yes
___ Yes
___ Yes
___ No
___ No
___ No
Have your medications caused any of the following SIDE EFFECTS? (Circle all that apply)
Vomiting
Itchiness
Constipation
Drowsiness Sweating
Loss of libido
Weight gain
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Since your last visit, have you had a pain injection? ___ Yes ___ No If yes, how much pain relief did you obtain with
the injection?
None 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Has your treatment improved any of the following aspects of your life?
Activities of daily living
Ability to work
Family life
___ Yes
___ Yes
___ Yes
___ No
___ No
___ No
Relations with people
Sleeping /rest
Depression/anxiety
Overall, has the treatment you are receiving made a positive change in your condition?
___ Yes
___ Yes
___ Yes
___ No
___ No
___ No
___ Yes
___ No
Opioid Attestation
I attest and certify that all of the following statements are true and factual:
___ I have used all medications prescribed to me exactly as prescribed.
___ I have reported all side effects to my physician.
___ I have not sold, given to someone else, or otherwise transferred my medications to anyone.
___ I have safeguarded my medications from theft.
___ I have not received, accepted, taken, or otherwise used any other opioid medications (narcotics) from any other
source, including from other physicians.
___ I have not received, accepted, taken, or otherwise used any illegal drugs.
___ I have not used alcohol while taking my opioid medications (narcotics).
___ All of the answers provided on this form are true and factual.
Patient‘s Signature _________________________________
List all your drug allergies _______________________________
List all other MEDICATIONS FOR PAIN you currently taking. Include PAIN CREAMS. Include dose and times per day taken
1)
2)
3)
4)
5)
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
___ Digabatran (Vigabatin)
Do you take any of the following blood thinners?
___ Plavix
___ Alteplase (Aclilyse)
___ Coumadin
___ Ticlopidine (Ticlid)
___ Lovenox
___ Apixoban (Elquis)
___ Heparin
___ Aspirin
___ Rivaroxaban (Xarelt
___ Edoxaban (Lixiana)
Are you currently enrolled in PHYSICAL THERAPY? ___ No ___ Yes If yes, when will you complete it _______________
PAST MEDICAL HISTORY Has your medical history changed since your last visit? ___ No ___ Yes, explain
__________________________________________________________________________________________________
__________________________________________________________________________________________________
PAST SURGICAL HISTORY Since your last visit, have you had any new surgery(ies)? ___ No ___ Yes
If yes, write the type of surgery(ies) _____________________________________________________________________
__________________________________________________________________________________________________
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REVIEW OF SYSTEMS
Circle all that apply
1. General
2. Eyes/ Ears/Nose/Throat
Weight gain or loss, unexplained hair loss, fever or chills, low energy, too sleepy
Eye pain, vision problems (blurred vision, loss of vision), hearing loss, swollen glands in
neck, sore throat/pain when swallowing, dental problems
Chest pain (sharp, crushing, or heaviness), heart racing (palpitations), fainting spells,
shortness of breath, swelling of legs (edema)
Shortness of breath, cough/coughing up blood
Increased appetite, decreased appetite, stomach pain, nausea/vomiting, diarrhea,
constipation
Pain when passing water (urination), blood in urine, urinating more than usual (day
and/or night), bladder Infection, pain during sex, changes in sex drive (libido)
Limited motion of arms or leg, joint pain, swelling/redness, numbness, tingling, or
weakness in arms or legs
Arm/leg weakness, new headaches, problems with memory or speech, tremors
Sadness, stress, seeing or hearing things, suicidal thoughts, feeling down, insomnia,
anxiety
Weight gain/loss, thirsty all the time, cannot stand temperature changes (heat/cold)
Swollen glands (armpits or groin)
Rash (palm of hands, sole of feet), changes in skin, sores or rash on skin
Hives/skin rashes, allergic reaction to foods
3. Cardiovascular
4. Respiratory
5. Gastrointestinal
6. Genitourinary
7. Musculoskeletal
8. Neurological
9. Psychiatric
10. Endocrine
11. Lymph
12. Skin
13. Allergies
____ No new problems
I attest that information I have provided is accurate and factual, and I can provide supporting information to its veracity.
Patient‘s Signature __________________________________
Date _____________________
DOCTOR’S NOTES
MRI:
_ Reviewed
XRAY: ___Reviewed
CT SCAN: ___Reviewed
EMG: ___ Reviewed
SOAAP-R Score: ____
PMQ-R Score: ____
DEPRESSION Score: ____
Medical Records: ___ Reviewed ___ Not Available
DPS REPORT: ___ Reviewed
Inclinometry and muscle strength test: ___ Done today ___ Reviewed
UDS REPORT: ___ Reviewed
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