SLUCare Pain Management Center
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SLUCare Pain Management Center PATIENT QUESTIONNAIRE Patient’s Last Name: First: Middle: Medical Record #: (for office use) Appointment Date: Appointment Time: Primary Care Physician: Date of Last Visit to PCP: Phone #: ( ) Referring Physician If Not PCP: Phone #: - ( Date pain started: ) - Briefly describe your primary pain complaint: Do you have pain in other locations? Pain radiates to my: Yes No If yes, please specify: Type of pain: Pain characteristics: (choose one) Head Arm Back Burning Aching Right side Middle only Neck Chest Hip Numbness Stabbing Left side Everywhere Shoulder Abdomen Leg Tingling Pain caused by: Both sides If work injury: No specific event Date: Work injury Ins Co: Car accident Case manager: Surgery Claim #: Did you hire an attorney? Yes Is a lawsuit pending? Yes Choose the number that describes your pain: (0=no pain and 10 worst pain imaginable) Pain pattern Continuous Comes and goes Brief momentary No /10 Pain intensity now /10 Pain at its least / 10 Pain at its worst / 10 Pain on average Rate the quality of your sleep: /10 (0= not at all restful and 10= completely restful) Do you have difficulty GETTING to sleep? Yes No Do you have difficulty STAYING asleep? Yes Page 1 of 5 SLUCare Pain Management Department PHONE (314) 977-5400 FAX (314) 977-5404 Last Updated May 2009 No No MEDICINES Where is your pain? Using the symbols listed below, mark on the drawing the areas where you feel your pain. If you feel more than one sensation in the same area, mark over that area with the additional symbols that apply. Please indicate all affected areas. SYMBOLS: Numbness Pins and Needles Burning Stabbing -------------- OOOOOO xxxxxxxxx ///////////// +++++++ Right Left Aching Left Page 2 of 5 SLUCare Pain Management Department PHONE (314) 977-5400 FAX (314) 977-5404 Last Updated May 2009 External (on or outside) E Right Internal (inside) I Medicine: Amount / # Times Per Day: Reason For Taking: MEDICAL PROBLEMS AND SURGERIES Please list your medical problems and surgeries including dates if possible: ALLERGIES Any known allergies? Yes No If yes, please list any medications or foods you are allergic to: Listed below are procedures commonly used in treating pain. If you have used any of the below treatments, please indicate the amount of benefit you experienced . Surgery Steroid Injection Physical therapy Aquatic therapy TENS unit Biofeedback Psych Counseling Other: Helpful Helpful Helpful Helpful Helpful Helpful Helpful Helpful Not Not Not Not Not Not Not Not Helpful Helpful Helpful Helpful Helpful Helpful Helpful Helpful SLUCare Pain Management Department PHONE (314) 977-5400 FAX (314) 977-5404 Last Updated May 2009 Worse Worse Worse Worse Worse Worse Worse Worse Page 3 of 5 PERSONAL HEALTH HISTORY Please indicate whether you currently have (C), or previously have had (P), any of the following conditions. All information is strictly confidential. C Constitutional Symptoms Fever P C Eye Pain Blurred Vision C Genitals / Bladder Painful urination Muscle / Joints Arthritis Bladder Infection Bursitis Fatigue Eye P Difficult Urination Fibromyalgia Frequent Urination Poor Posture Blood in Urine Sciatica Testicle Problem Spinal Curvature Flank Pain Swollen Joints STD Joint Replacement Nocturia Back Surgery Glaucoma Eye Discharge Glasses or Contacts Light Sensitivity Sexual Dysfunction Ear Ear Discharge Ringing or Pain Hearing Difficulty /Aids Hot Flashes Menstrual Cramps Pain and /or Numbness Arms Excessive Menstruation Shoulder Irregular Menstruation Nose Pain Menopause Elbows Painful Menstruation Neck Vaginal Discharge Hips Pain on Intercourse Legs Kidney Disease Knees Discharge Congestion Hands Eye Discharge Feet Glasses or Contacts Tailbone Lungs Painful Breathing Mouth / Throat Denture Productive Cough Jaw/ tooth pain Bronchitis Mouth Sores Sore Throat Hoarseness Pneumonia Allergic / Other Hay Fever Allergies (not drugs) Emphysema Shortness of Breath TB Nutrition Weight Loss/ Gain Asthma Poor Appetite Nutritional Supplement Page 4 of 5 SLUCare Pain Management Department PHONE (314) 977-5400 FAX (314) 977-5404 Last Updated May 2009 Cancer AIDS/HIV Lupus P C P C P C Heart High Blood Pressure Skin / Breast Skin Rash Brain / Nerves Headache Chest Pain Itching Multiple Sclerosis Heart Attack Easy Bruising Seizures Abnormal Heart Rhythm Shingles Head Injury Swelling of Ankles Skin Cancer Stroke Pacemaker Lumps in Breasts Tremors Blood Clot Congested Breasts Dizziness Blood Thinners Light Sensitivity Stomach / Bowels Blood/ Glands Loss of Coordination Sweats Abdominal Pain Memory Loss Thyroid Disease Heartburn Alzheimer’s Diabetes Hiatal Hernia Depression Leukemia Nausea/ Vomiting Anxiety Bruising Constipation Alcoholism Bleeding Disorder Diarrhea Swollen Glands Thoughts of Suicide Ulcers Irritability Liver/Gallbladder Issues Weakness Black, Bloody Stool Numbness/Tingling Family Medical History: Has anyone in your family ever had any of the following? FATHER MOTHER BROTHER SISTER GRANDPARENT ANXIETY CANCER CHRONIC PAIN DEPRESSION DIABETES HEART DISEASE HIGH BLOOD PRESSURE PHYSICAL DISABILITY SCHIZOPHRENIA STROKE SUICIDE THYROID DISEASE Social History: Substance Abuse Quantity (circle per day or per week) Beer per DAY / per WEEK Alcoholic Beverages per DAY / per WEEK Use of Tobacco per DAY / per WEEK Illegal Drugs per DAY / per WEEK Retired Employed Unemployed Marital Status: Page 5 of 5 SLUCare Pain Management Department PHONE (314) 977-5400 FAX (314) 977-5404 Last Updated May 2009 Occupation: P SLUCare Pain Management Department PHONE (314) 977-5400 FAX (314) 977-5404 Last Updated May 2009
