New Patient History
* denotes required fields
Patient's Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Email
example@example.com
Gender
*
Male
Female
Is this visit for Trigeminal Neuralgia?
Yes
No
Which side is the pain located
*
Right
Left
Both
How long has it been hurting?
*
Date of onset?
*
Is it getting progressively ?
*
better
worse
no change
Symptoms
Please describe your current symptoms. (If your current symtom is pain ,please put the area of your pain and where the pain radiates to. Also list any associated symptoms. ex. numbness, tingling, etc)
*
What was the onset of Symptoms
*
Sudden
Slowly
Developing
Other
Any numbness?
*
Yes
No
Location of Numbness
*
Any Weakness?
*
Yes
No
Location of Weakness
*
Any Pain?
*
Yes
No
Location of Pain
*
Is your pain
*
Constant
Off and On
Other
Is your Pain
*
Sharp
Deep
Superficial
Burning
Electric Shock-like
Rate your level of pain
*
1
2
3
4
5
6
7
8
9
10
No Pain
Extreme Pain
1 is No Pain, 10 is Extreme Pain
Facial Pain Questionaire
Do you have pain in your face that starts very rapidly,lasts seconds to a few minutes and then stops suddenly?
Yes
No
Do you have pain in your face that stays always on the same side of the face either the right or the left, but it does not cross over to the other side?
Yes
No
Does the pain feel like it comes on rapidly then disappears rapidly with periods of time between episodes that may last minutes,hours or even days to weeks and even years?
Yes
No
Does the pain feel like a "live wire" of electricity is rapidly touched to the affected side of the face and then rapidly removed?
Yes
No
Does it feel like the pain can be triggered by such common things as eating,brushing the teeth,shaving,washing the face,cool air blowing on face,touching the face in particular areas etc?
Yes
No
Does the pain usually stay in the same area or tegion of the face with recurrent episodes?
Yes
No
Do you remember exactly when and where you were when you first started having the pain?
Yes
No
Is your pain usually very brief in duration (seconds to minutes) often with recurrent episodes that is similar to getting your face shot with a machine gun of electrical jolts or like being repeatedly hit with a taser gun to the face with electricity?
Yes
No
Does your pain involve feelings of electrical shocks, stabbing a knife, or a bolt of lightning?
Yes
No
Since you had your first bout of facial pain have you had periods of time (weeks,month and even years) when you were pain free?
Yes
No
Have you taken any anti convulsant medications: Tegretol, Dilantin, neurontin, Trileptal, Topamax, Zonegran, baclofen etc for your pain?
Yes
No
Did you experience any periods of major relief from any of these medications?
Yes
No
Did you have to stop or cut back the dosage due to side efects from the medications?
Yes
No
Are you currently on these medication?
Yes
No
Have you had any percutaneous, surgical or radiosurgical treatments for facial pain?
Yes
No
Did you get relief from any of these procedure in the prior question at least for a period of time before the pain recurred?
Yes
No
Was the first onset of your pain spontaneous in onset without known precedent cause?
Yes
No
Has the course of the painful episodes changed for the worse with time so that the frequency of bouts of pain has increased while time between bouts has decreased as time has gone by since the first painful episode?
Yes
No
Does the pain feel like it is created just from opening and closing of the jaw?
Yes
No
Do you have multiple sclerosis?
Yes
No
Did your pain start in association with a outbreak of rash on your face (shingles)?
Yes
No
Did your pain start with some trauma to the face?
Yes
No
Did your pain start after a dental or facial surgery was done?
Yes
No
Does the pain feel like it involves both sides of the face?
Yes
No
Does the pain feel like it is constantly present without any interventing periods of freedom from pain?
Yes
No
Does the face feel constantly numb or weak?
Yes
No
Submit
Print Form
Should be Empty: