HOWDY FORM (F/U Intake form)

PATIENT PAIN QUESTIONNAIRE
PATIENT NAME
DATE

MonthDayYear
Date
BetterSameWorse
2 Where is the worst area of pain
SharpBurningAchingStabbingOther
Occasional (present 25% of the time)Intermittent (present 50% of the time)Frequent (75% of the time)Constant (present 90-100% of the time)
Minimal (an annoyance)Slight (tolerable but some activities limited by pain)Moderate (tolerable but most activites limited by pain)Severe (all activities limited by pain)
YesNoIf yes, please describe:
YesNoIf yes, please describe:
YesNoIf yes, please describe:
9. What treatments have you started since your last visit? (i.e., PT, massage injections, etc.)
10. How much does your pain interfere with the following?

0 = Does not interfere 10= Completely interferes
General Activity
Mood
Walking Ability
Normal Work
Personal Relationships
Sleep
Enjoyment of Life
Please choose any of the following symptoms that you experience:
feverchillsfatigue
change in vision
shortness of breathcoughsleep apnea
chest pain
constipationnauseavomitingdiarrhea
numbnessheadachesdizziness
depressionanxietysuicidal thoughtsaddiction
incontinence of bowel/bladder
sore jointsjoint swellingspasms
How satisfied are you with your care? 0=Not at all 10=Completely
Should be Empty:

PATIENT PAIN QUESTIONNAIRE