Abe T. Haliczer, M.D.
Interventional Pain Management
Please complete all information. Our records are strictly confidential and no one
is permitted to review this information without your written approval.
Personal information
Name: _____________________ Date of Birth: __________ Age: ________
S.S. #: ________ Family MD: ____________ Referring MD: ______________
Pain History
1. When did your pain start? ________________________________________
2. What event brought on the pain? __________________________________
3. Character of the pain:
FREQUENCY:
CONSTANT
75% OF THE TIME
50% OF THE TIME
25% OR LESS
ACHING
NUMBNESS
BURNING
TINGLING
SHARP
DULL
OTHER ______________
TYPE OF PAIN:
4. Activities that affect pain:
Decrease Increase No change
Does the pain affect:
LYING DOWN
SLEEP
STANDING
APPETITE
SITTING
RELATIONSHIPS
WALKING
EMOTIONS
COUGHING OR
SNEEZING
CONCENTRATION
OTHER_________
5. Please circle the level of your pain on a scale of 0 to ten.
(0 =no pain, 10 = Worst imaginable pain)
Present level of pain:
0
1
2
3
4
5
6
7
8
9
10
Worst pain:
0
1
2
3
4
5
6
7
8
9
10
Least pain:
0
1
2
3
4
5
6
7
8
9
10
Page 2
6. On the diagram, shade in the areas where you feel pain. Put an X on the
area that hurts most.
7. Please list other treatments for your pain problem:
TREATMENT
DATES OF TREATMENT
WAS THIS HELPFUL?
ACCUPUNCTURE
____________________
___________________
CHIROPRACTIC
____________________
___________________
INJECTIONS
____________________
____________________
PHYSICAL THERAPY ___________________
____________________
OTHER
____________________
____________________
MEDICATIONS
____________________
____________________
8. Has your pain forced you to stop working?
(
) Yes
(
) No
9. Would you return to work if you had less pain? (
) Yes
(
) No
10. Are you currently being treated under Workers Compensation?
( ) Yes
( ) No
11. Are you currently receiving disability benefits? (
) Yes
(
) No
12. Are you currently involved in legal action related to your pain problem?
( ) Yes
( ) No
If yes, describe the current litigation
Page 3
Diagnostic Testing
13.
MRI _________
CT SCAN __________
date
EMG _________
date
date
OTHER _______________________________
Medical History
14. Please check any of the following conditions you have:
a.
b.
c.
d.
e.
(
(
(
(
(
)
)
)
)
)
Diabetes
f.
Cancer: type __________ g.
Heart problems (angina) h.
Asthma, Emphysema
i.
Thyroid Disease
j.
(
(
(
(
(
) High blood pressure
) Arthritis
) Ulcer
) Bleeding problems
) Seizures
k. (
l. (
m. (
n. (
o. (
) Kidney disease
) HIV/ AIDS
) Hepatitis
) High Cholesterol
) Other: _____
15. Current medications and Drug allergies:
Current medications:
Drug Allergies:
 Shellfish  Contrast/Dye
16. Surgical History:
DATE
PROCEDURE
PHYSICIAN
FACILITY
Page 4
Social History
17. What is your present employment status?
memaker
18. Current occupation or last job? ____________________________
19. Do you smoke?
( ) Yes
20. Alcoholic beverages: (
( ) No
) Never (
) Socially (
21. Do you use recreational / street drugs? (
) Yes
) Regularly (_____/week)
(
) No
22. If you are female, when was your last menstrual period? _______________
23. What is your current marital status?
( ) Single ( ) Married ( ) Separated (
) Divorced ( ) Widowed
Review of Systems
24.
a. ( ) Fever, weight loss, sweats e. (
b. ( ) Cough, sputum production, f. (
shortness of breath, wheezes
c. ( ) Weakness or paralysis of
g. (
arms and/or legs.
d. ( ) Headache
h. (
MD Signature
) Chest pain, palpitations
i.
) Abdominal pain, change in
bowel habits, nausea
j.
) History of easy bruising or k.
using blood thinners.
l.
) Lightheadedness, dizziness,
vision changes.
____________________________
( ) Change in
bladder habit
( ) Swelling
( ) Rash
( ) Other:
________