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  • 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

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  • PAIN PATIENT QUESTIONNAIRE

    It is very important that this form be filled out completely before coming for your visit!
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  • IDENTIFICATION:

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  • CHIEF COMPLAINT

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

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  • HISTORY OF PRESENT ILLNESS

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

  • 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.

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

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  • Format: (000) 000-0000.

  • Medical History

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  • HABITS

  • WORK AND LIFE STYLE:

  • Finishedth grade

  • College(yrs)

  • Post-Graduate

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  • FAMILY HISTORY

  • ORIGINAL FAMILY

  • MARRIAGE

  • CHILDREN

  • Date: Age:

  • Reason:

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

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