Pain Management New Patient Forms

Patient Information
Patient Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone *

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell Phone

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

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

Area Code Phone 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 time Employed part time Unemployed Retired Disabled
Are you on disability?

Yes No
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: *

Current Former Never
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:

Single Married Divorced Widow Seperated
Mother:

Living Deceased
Cause of death:
Father:

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

Workmans Comp Motor vehicle claim Neither
Workmans Comp or Motor Vehicle claim case manager:
Phone:
Are there legal/occupational issues pending in regard to your pain condition?

Yes No

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: *

Shooting Sharp Burning Sore Annoying Intense Agonizing Stabbing Pinching Tingling Aching Miserable Radiating
Where is your pain? *
Does your pain go anywhere else?

Yes No Sometimes
If yes, where?
Did major life changes occur prior to onset?
The pain is getting:
How did it start?

Work injury Motor accident Following surgery Cancer No obvious cause
When did it start?

Month Day Year
Date
Did it start:

Gradually Suddenly Not sure
What makes the pain worse? *

Sitting Walking Heat Exercise Standing Lying down Cold Immobilization Brace Stretching
What makes the pain better? *

Sitting Walking Heat Exercise Standing Lying down Cold Immobilization Brace Stretching
What time of day is your pain worse? *

Morning Noon Afternoon Night Always the same
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? *

Morning Noon Afternoon Night Always the same
Which statement best describes your pain? *

Always present, always the same intensity Always present, intensity varies Usually present, but has pain free periods of 1+ hours Often present, but has pain free periods of 1+ hours Often present, but is pain free most of the day Occasionally present, has pain once to several times per day, lasting a few minutes to an hour Occasionally present for brief periods of time Rarely present has pain occasionally during the week
Does pain interrupt your sleep? *

Yes No
If yes, how many times: *
What treatments have you tried for your pain? *

Exercise Acupuncture Heat/Ice Biofeedback Mental health professional Steriod epidurals Facet joint injections Massage Brace Nerve Block TENS unit Traction Surgery Chiropractic care Physical Therapy Occupational Therapy Osteopathic treatment
Investigations/Diagnostic studies: Tests done in the past year to evaluate your pain: *

X-Ray CT Scan MRI EMG Myelogram Thermogram Epidurogram Laboratory tests
Should be Empty:

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Patient Information

Primary Insurance

Secondary Insurance

Employment Information

Social History

Pain Assessment