Pain Questionnaire

710 S Broadway, Ste 212, Walnut Creek, CA 94596

490 Post Street, Suite 450, San Francisco, CA 94102

180 E Leland Rd, Suite A, Pittsburg, CA 94565

1320 Apple Ave, Suite 203, Hayward, CA 94541

5330 Madison Ave, Suite F, Sacramento, CA 95841

291 S La Cienega Blvd, Ste 108, Beverly Hills, CA 90211

Statewide Telephone and Central Fax (925) 388-9800

Patient Name*

Today's Date:

Date of Birth*

Date

Age*

What is your dominant hand:*

RightLeft

What is your Height:*

What is your Weight:*

HISTORY OF PRESENT INJURY:

Rank problem areas, worse problem being #1, next #2, etc., and in terms of the pain and interference with your daily fulnction.

Rank Areas of Pain from worse problem (#1), next worse problem (#2), and so on.*

	Rank Pain Area with 1 being the main problem
Headache & Face Pain
Neck Pain
Shoulder Pain
Arm & Elbow Pain
Wrist & Hand Pain
Chest and/or Abdomen Pain
Pelvic Pain
Upper/Mid Back Pain
Low Back Pain
Hip Pain
Knee Pain
Ankle & Feet Pain

NEXT FOUR SECTIONS are NECK PAIN, UPPER LIMB PAIN, LOW BACK PAIN, LOWER LIMB PAIN. You need to ONLY answer the sections that apply to you. Eg. If your Neck Pain radiates to your arm, fill out only the NECK section. Or if you have an elbow injury, then fill UPPER LIMB PAIN only.

NECK PAIN: (Starts at neck and radiates to arms)

Date NECK PAIN Began

Date

How did NECK PAIN begin? Accident, injury, illness, gradual onset

FREQUENCY OF NECK PAIN:

	Without Medications or Treatments
Constant more than 90%
Frequent more than 75%
Intermittent 50% of time
Occasional 25% of time

PAIN SCALE OF NECK PAIN: One to 10

	Without Medications or Treatment
9 - Severe Can't move
8 ModSevere Freq lying down
7 ModSevere Limits activity to less than 1/4 hr
6 - Moderate Limits activity to less than 1/2 hr
5 - Moderate Limits activity to less than 1 hr
4 - Moderate
3 - Slight Pain with activity

CHARACTER of NECK PAIN - check all that applies

Dull or AchySharp or StabbingShootingBurning or Throbbing

NECK PAIN Radiates to:

	Pain Travels to
Head Right
Head Left
Upper Back Right
Upper Back Left
Shoulder/Arm Right
Shoulder/Arm Left
Wrist/Hand Right
Wrist/Hand Left

Associated with:

Numbness and tinglingWeakness

Aggravating and Relieving Factors to Neck Pain:

	Aggravating Factors
Sitting
Standing or Walking
Bending, Lifting
Lying down

Relieving Factors to Neck Pain:

	Relieving Factors
Sitting
Standing or Walking
Lying down

NECK PAIN SYMPTOMS ARE

ImprovingWorseningStaying same

UPPER LIMB PAIN: (Starts in Upper Limbs)

Date Upper Limb Pain Began:

Date

How did Upper Limb Problem began:

UPPER LIMB PAIN (Separate from Neck, starts in Upper Limbs - check where the problems are)

	Right	Left
Shoulder
Elbow
Wrist
Hand

FREQUENCY OF UPPER LIMB PAIN:

	Right Side	Left Side
Constant more than 90%
Frequent more than 75%
Intermittent 50% of time
Occasional 25% of time

PAIN SCALE OF UPPER LIMB PAIN: One to 10

	Right Side	Left Side
9 - Severe Can't move
8 ModSevere Pain worse from moving
7 ModSevere Painful to lift 10 pounds
6 - Moderate
5 - Moderate Painful to Lift and Carry 10 pounds
4 - Moderate
3 - Slight Able to do things, but with pain

CHARACTER OF UPPER LIMB PAIN - check all that applies

	Right Side	Left Side
Dull or Achy
Sharp or Stabbing
Shooting
Burning or Throbbing

UPPER LIMB PROBLEM radiates to and/or associated with:

	Pain
Head Right
Head Left
Shoulder Right
Shoulder Left
Arm Right
Arm Left
Elbow Right
Elbow Left
Wrist Right
Wrist Left
Hand Right
Hand Left

ASSOCIATED WITH

	Right Side	Left Side
Numbness & Tingling
Weakness

Aggravating and Relieving Factors to UPPER LIMB Pain: Check if applies

	Aggravating	Relieving
Sitting
Standing / Walking
Lifting
Lying down

UPPER LIMB SYMPTOMS ARE

ImprovingWorseningStaying same

LOW BACK PAIN: (Starts at back and radiates to legs)

Date LOW BACK PAIN Began

Date

How did LOW BACK PAIN begin?

FREQUENCY of LOW BACK PAIN

	Without Medications or Treatment
Constant more than 90%
Frequent more than 75%
Intermittent 50% of time
Occasional 25% of time

PAIN SCALE OF LOW BACK PAIN: One to 10

	Without Medications or Treatment
9 - Severe Can't move
8 ModSevere Freq lying down
7 ModSevere Limit < 1/4 hr
6 - Moderate Limit < 1/2 hr
5 - Moderate Limit < 1 hr
4 - Moderate
3 - Slight Pain with activity

CHARACTER of LOW BACK PAIN - check all that applies

Dull or AchySharp or StabbingShootingBurning or Throbbing

LOW BACK PAIN Radiates to:

	Pain
Midback Right
Midback Left
Hip Right
Hip Left
Thigh Right
Thigh Left
Lower Leg Right
Lower Leg Left
Foot Right
Foot Left

ASSOCIATED WITH:

Numbness and TinglingWeaknessIrritable Bladder or Bowel

Aggravating and Relieving Factors to LOW BACK PAIN:

	Aggravating	Relieving
Sitting
Prolonged Standing or Walking
Bending or Lifting
Lying down
Use of Cane

LOW BACK SYMPTOMS ARE

ImprovingWorseningStaying same

LOWER LIMB PAIN: (Starts in legs and radiates to legs)

Date LOWER LIMB PAIN Began

Date

How did the LOWER LIMB PAIN begin?

LOWER LIMB PAIN:

	Right	Left
HIP
KNEE
ANKLE
FOOT

FREQUENCY of LOWER LIMB PAIN

	Right Side	Left Side
Constant more than 90%
Frequent more than 75%
Intermittent 50% of time
Occasional 25% of time

PAIN SCALE OF LOWER LIMB PAIN: One to 10

	Right Side	Left Side
9 - Severe Can't move
8 ModSevere Painful just moving
7 ModSevere Painful to stand
6 - Moderate Limits walking to less than 1/2 hr
5 - Moderate Limits walking to 1 hour
4 - Moderate
3 - Slight Able to walk but with pain

CHARACTER OF LOWER LIMB PAIN - check all that applies

	Not Satisfied	Somewhat Satisfied
Dull or Achy
Sharp or Stabbing
Shooting
Burning or Throbbing

LOWER LIMB PAIN Radiates to:

	Pain
Hip Right
Hip Left
Thigh Right
Thigh Left
Lower Leg Right
Lower Leg Left
Foot Right
Foot Left

ASSOCIATED WITH:

	Right Side	Left Side
Numbness and/or Tingling
Weakness

Aggravating and Relieving Factors to LOWER LIMB PAIN:

	Aggravating	Relieving
Sitting
Standing or Walking
Lying down
Use of cane

LOWER LIMB SYMPTOMS ARE

ImprovingWorseningStaying same

Date when symptoms began*

Date

Accident or Illness?*

Pain throughout Day:

	Morning	Afternoon	Evening
When is the pain better?
When is the pain worse?

Does the Pain impact:*

	Yes	No
Can you Walk, Bathe and Dress without assistance?
Can you sit through a movie?
Can you walk without assistance for over 30 minutes?
Can you get off the floor without using your hands?
Can you lift a heavy bag of groceries without problems?
Can you carry a 10 pound bag 50 feet?
Can you do all your recreational and work activities?
Does the pain affect relationships with family and friends?

PRIOR TREATING DOCTORS:*

	Name of Doctor and City
Primary Care Physician
Pain Management
Specialist/Surgeon
Chiropractor or PT or Acupuncturist
Chiropractor or PT or Acupuncturist

PRIOR WORKUP:*

	No	Yes	MM/YR done	Results of Abnormal Findings
Labs
X-rays
MRI's
EMG Nerve Studies

PRIOR TREATMENT FOR PRESENT PAIN*

	No	Yes	Month/Year	Did it help?
Physical Therapy
Exercise
Chiropractic
Osteopathy
Acupuncture
Trigger Points Injections
Joint Injections
Epidural/ Facet/ Nerve Blocks
PRP / Stem Cells
Surgery / Stimulator

PAST MEDICAL HISTORY: Medical problems treated now or in past*

	Yes	No
Seizure
Stroke
Glaucoma
Thyroid
Diabetes
High Blood Pressure
High Cholesterol
Heart Disease
Irregular Heart Rhythm
COPD or emphysema
Asthma
Heartburn, GERD, or Reflux Gastritis
Pancreatitis
Liver Disease or Hepatitis
Kidney problems
Prostate problems
Pelvic / Genital problems
Arthritis
Chronic Pain
Chronic Infection
Cancer
Addiction
Depression
Anxiety

Have you had any Surgeries?*

YesNo

PAST SURGERIES, write "none" if none:*

	Month/Year	Name of Operation Performed	Did it help?
Operation 1
Operation 2
Operation 3
Operation 4

FAMILY HISTORY:*

	Mother	Father	Siblings	Children
Thyroid
Diabetes
Hypertension
Heart Disease
Stroke
Arthritis
Autoimmune
Cancer
Addiction
Depression Anxiety

SOCIAL HISTORY:*

	Yes	No
Are you married or live with a partner?
Do you live with other people?
Do you have children?
Do you smoke cigarettes?
Do you drink alcohol daily?
Do you use any street drugs?

Do you have any ALLERGIES TO DRUGS OR ANESTHESIA:*

YesNo

List Drugs Allergies, write "none" if none:*

	Drug Name	Reaction (rash, swelling, short of breath
Drug #1
Drug #2
Drug #3

Are you taking any PRESENT MEDICATIONS, or Over-the-Counter Supplements?*

YesNo

PRESENT MEDICATIONS, list ALL medications, write "none" if none:*

	Medication	Strength	How Often	For What Condition	Prescribing Physician
Rx #1
Rx #2
Rx #3
Rx #4
Rx #5
Rx #6
Rx #7
Rx #8
Rx #9
Rx #10
Rx #11
Rx #12

Have you tried any Medications in the Past for your Pain?*

YesNo

PAST DRUGS USED for your pain, write "none" if none:*

	Medication	Strength	Did it help?	Why did you stop?
Rx #1
Rx #2
Rx #3
Rx #4

REVIEW OF SYSTEMS (General Health): Do you have any problems with*

	Yes	No
Fever, Chills, Sweating
Sleeping less than 6 hours
Headaches. Migraines.
Difficulties in Vision
Difficulties in Hearing
Nasal or Sinus Congestion.
Unable to smell or taste
Problems with teeth or gums.
Sore throat. Swollen glands.
Chest pain
Rapid or irregular heart rate
Shortness of Breath. Wheezing
Coughing.
Nausea. Vomiting.
Heartburn. Abdominal pain.
Yellow jaundice
Diarrhea. Constipation.
Bright red blood in stool
Dark stool
Poor libido
Pelvic pain.
Sexual Dysfunction (ED in men, FSD in women)
Frequent or Night time urination
Burning. Urgency to urinate.
Weak urine flow. Dribbling.
Wake up to urinate
Weakness. Fatigue.
Joint pain. Muscle pain.
Problems with Balance
Skin rashes. Acne. Moles.
Easy Bruising. Nosebleeds.
Feet swelling
Hair loss
Numbness. Tingling.
Seizures
Forgetful
Repeatedly or overly worried
Rapid thoughts
Trouble falling asleep
Snoring
Feeling sad or depressed
Feeling hopeless, or suicidal thoughts.
Weight Loss, or Poor Appetite.
Weight Gain, or Excessive Appetite

Signed*

Today's Date

Vital Total Health Medical Group, Inc.

PAIN QUESTIONNAIRE