Pain Management New Patient Forms

Patient Information
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Patient E-Mail*
Pharmacy Name*
Pharmacy Phone Number*

Area CodePhone Number
Emergency Contact*
Relationship to Patient*
Emergency Contact Phone Number*

Area CodePhone Number
Primary Care Doctor:*
Referring Doctor:*
Primary Insurance
Primary insurance company
Policy#
Group#
Insurance address:
Name of Insured:
Relation to insured:
Name of responsible party:
If other than self,please provide address:
Responsible party phone number:
Secondary Insurance
Company:
Policy#:
Group:
Address:
Relation to Insured:
Name of responsible party:
If other then self, please provide address:
Phone:
Allergies and reactions*
Medications taken: include medicine, dose, and frequency*
(Including narcotic/controlled medications & pain meds)
Employment Information
Are you currently

Employed full timeEmployed part timeUnemployedRetiredDisabled
Are you on disability?

YesNo
Occupation:
Employer Name:
Employer Address:
Work phone:
Previous Surgeries (include dates-estimate)*
Do you have any past medical history or problems (i.e.. illness, trauma, emotional stress, addictions, drug abuse, or anything else that will help us clearly understand your health condition)?*
Social History
Smoking status:*

CurrentFormerNever
If you smoke cigarettes (or other substances), how many do you smoke per day?
How often do you drink alcohol?*
How much at at time?
Other drug use:
Marital status:

SingleMarriedDivorcedWidowSeperated
Mother:

LivingDeceased
Cause of death:
Father:

LivingDeceased
Cause of death:
With whom do you live:
Is the visit today:*

Workmans CompMotor vehicle claimNeither
Workmans Comp or Motor Vehicle claim case manager:
Phone:
Are there legal/occupational issues pending in regard to your pain condition?

YesNo

Medical History: check all that apply

	Myself
Pregnancy
Hearth Attack
Angina/Chest
Irregular Heartbeat
Heart Murmur
High blood pressure
Fainting episodes
Congestive heart failure
Shortness of breath/Lung dx
Emphysema
Asthma
Recent respiratory infection
Seizures/Epilepsy
Stroke
Depression/mental heath issues
Headaches/Migraines
Peripheral Neuropathy
HIV/Aids
Diabetes
Thyroid disease
Hepatitis -(type)
Ulcers,heartburn,GERD
Kidney disease
Glaucoma
Bleeding problems
Liver disease
Hearing problems
Cancer-(type)
Joint disease/Athritis
Bladder problems
Visual problems
Bowel problems
Dermatological conditions

Pain Assessment
What does your pain feel like:*

ShootingSharpBurningSoreAnnoyingIntenseAgonizingStabbingPinchingTinglingAchingMiserableRadiating
Where is your pain?*
Does your pain go anywhere else?

YesNoSometimes
If yes, where?
Did major life changes occur prior to onset?
The pain is getting:
How did it start?

Work injuryMotor accidentFollowing surgeryCancerNo obvious causeOther
When did it start?

MonthDayYear
Date
Did it start:

GraduallySuddenlyNot sure
What makes the pain worse?*

SittingWalkingHeatExerciseStandingLying downColdImmobilizationBraceStretchingOther
What makes the pain better?*

SittingWalkingHeatExerciseStandingLying downColdImmobilizationBraceStretchingOther
What time of day is your pain worse?*

MorningNoonAfternoonNightAlways the sameOther
On a scale of 1-10, how bad is your pain at the best?*
On a scale of 1-10, how bad is your pain at the worst?*
What time of day is your pain least severe?*

MorningNoonAfternoonNightAlways the sameOther
Which statement best describes your pain?*

Always present, always the same intensityAlways present, intensity variesUsually present, but has pain free periods of 1+ hoursOften present, but has pain free periods of 1+ hoursOften present, but is pain free most of the dayOccasionally present, has pain once to several times per day, lasting a few minutes to an hourOccasionally present for brief periods of timeRarely present has pain occasionally during the week
Does pain interrupt your sleep?*

YesNo
If yes, how many times:*
What treatments have you tried for your pain?*

ExerciseAcupunctureHeat/IceBiofeedbackMental health professionalSteriod epiduralsFacet joint injectionsMassageBraceNerve BlockTENS unitTractionSurgeryChiropractic carePhysical TherapyOccupational TherapyOsteopathic treatment
Investigations/Diagnostic studies: Tests done in the past year to evaluate your pain:*

X-RayCT ScanMRIEMGMyelogramThermogramEpidurogramLaboratory testsOther
Should be Empty:

Patient Information

Primary Insurance

Secondary Insurance

Employment Information

Social History

Pain Assessment