• Image field 3

  • 7191 Cahaba Valley Rd, Suite 204, Birmingham, Alabama 35242-6402 

    Phone: (205) 995-9967 FAX: (205) 995-0635 1-888-436-4560

    http://www.southernpain.com

  • For Office Use Only

  • Wt:

  • T:

  • P:

  • R:

  • BP:

  • Ht:

  • PAIN PATIENT QUESTIONNAIRE

    It is very important that this form be filled out completely before coming for your visit!
  • Today's Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • IDENTIFICATION:

  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • CHIEF COMPLAINT

    Please list your pain site in order of importance (rank the worst problem, as •a" the next as "b", etc.)

  • A

  • B

  • C

  • HISTORY OF PRESENT ILLNESS

    Please list your pain site in order of importance (rank the worst problem, as •a" the next as "b", etc.)
  • Date when your pain began?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Did this pain begin:*
  • How did this pain begin? (check)*
  • Is the pain the same as now as it was when it began?*
  • Is there a time of day that you pain is worse?*
  • PLEASE INDICATE WHICH DIAGNOSTIC PROCEDURES (TESTS) YOU HAVE HAD FOR THIS PAIN PROBLEM

  • CTScan Date: Where:

  • Myelogram Date: Where:

  • EMG Date: Where:

  • Discogram Date: Where:

  • Bone Scan Date: Where:

  • MRI Date: Where:

  • Bone Mineral Density (BMD) (Test for Osteoporosis) Date: Where:

  • Vertebral Fracture Assessment (VFA) Date: Where:

  • Location and Type of Pain

  • Please check those words that describe your pain, as mild, moderate, or severe:*

  • You will be using the MANKOSKI Pain Scale to estimate the level of your pain. Please note that the subjective experience of pain varies from person to person. In order to make your pain rating more valid, please read the following descriptions of the various pain levels and physical responses. Please be realistic in your pain rating, so we can help you better.

    0 - Pain free
    1 - Minor annoyance
    2 - Annoyance
    3 - Distracting; mild painkillers needed (aspirin, Tylenol).
    4 - Cannot be ignored; Mild painkillers remove pain for 3-4 hours.
    5 -  Cannot be ignored for more than 30 minutes. Mild painkillers decrease pain for 3-4 hours.
    6 - Cannot be ignored for any length of time. Stronger painkillers (codeine, narcotics) reduce pain for 3-4 hours. 
    7 - Cannot concentrate; interferes with sleep. Stronger painkillers are only partially effective.
    8 - Physical activity is severely limited. Nausea and dizziness set in as factors in pain.
    9 - Unable to speak. Crying out or moaning uncontrollably; near delirium
    10 - Unconscious. Pain makes you pass out.

  •

  • On the same scale (0 = no pain; 10 = the worst), rate your pain at its WORST: * At its LEAST (best): *

  • PAIN MODIFIERS. How is your pain changed? For each of the following please check the appropriate box: The following make your pain ....*
    Rows
  • Please list ALL the treatments you have had and are currently having for your pain. Include operations. hospitalizations. anesthetic procedures, nerve blocks, physiotherapy, and psychological treatment.
    Rows
  • Did it Help?
    Rows
  • Did you have any surgeries for this pain condition?
  • Did they/it help?
  • CURRENT MEDICATIONS. Please list ALL medications/ or drugs you are taking NOW for any reason, whether PRESCRIBED by a doctor or not (include home remedies; painkillers; over-the-counter medications; birth control pills).
    Rows
  • PREVIOUS MEDICATIONS. Please list ALL medications or drugs you have tried in the past for any reason, whether PRESCRIBED by a doctor or not (include home remedies; painkillers: over-the-counter medications; birth control pills).
    Rows
  • Format: (000) 000-0000.

  • Medical History

  • ALLERGIES
  • Have you recently taken? Put an X on YES or NO*
    Rows
  • Have you ever had a history of malignancy (cancer)?*
  • Approximate date discovered:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Currently receiving treatments (such as chemotherapy or radiation)?*
  • Have you had or do you presently have any of the following problems:

  • HABITS

  • Do you smoke cigarettes?*
  • Do you use other tobacco porducts?*
  • Do you drink alcohol?*
  • Recreational drug use?

  • WORK AND LIFE STYLE:

  • Education

  • Finishedth grade

  • College(yrs)

  • Post-Graduate

  • Are you presently working?*
  • If you are not working presently:
    Rows
  • Do you exercise regularly?*
  • Do you own any type of exercise equipment?
  • HOME ENVIRONMENT
    Rows
  • HOME ENVIRONMENT
    Rows
  • Are you getting any help?

  • FAMILY HISTORY

  • ORIGINAL FAMILY
  • Have any immediate family members died?*
  • Has anybody in your family had back or neck surgery?*

  • MARRIAGE
  • What is your partner’s occupation?*

  • CHILDREN
  • Any children deceased?*

  • Date: Age:

  • Reason:

  • Date of birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • REVIEW of SYSTEMS: Check the box for EACH symptom you have):

  • General/Constitutional
  • Head / ENT
  • Eyes
  • Respiratory
  • Heart & Circulation
  • Gastrointestinal
  • Musculoskeletal
  • Psychiatric
  • Breasts
  • Skin
  • Neurological
  • Endocrine
  • Hematologic
  • Genitourinary
  • Allergic/ Immunologic
  • Urinary
  • Male Genitalia
  • Female Genitalia
  • Should be Empty: