Pain Management History Form Logo

  • ORA History Form

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  • Present History

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  • Where is your pain now?

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  • Pain Rating Scale

    Please select a rating that corresponds to the area of your body that you feel pain and its severity. Rate how much pain hurts on an average day from "No Pain" on the left to "Worst Pain I Can Possibly Imagine" on the right.
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  • 12. Functional Activities - I can comfortably:

    Stand for minutes.
    Sit for minutes.
    Walk for minutes.

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  • 15. Which of the following treatments have you had for this problem?

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  • My present job involves:

    Hours sitting
    Hours standing
    Lifting pounds

  • 19. If unemployed or not currently working:

  • Past Medical History

    Do you have a history of any of the following: (Check all that apply)

  • Cardiac Procedures:
    Indicate any cardiac procedures or tests and where and when they were done.

  • Allergies:

  • How many years have you used tobacco and how much per day?
    For years packs/cans per day

  • ORA staff to fill out:
    P R Temp

  • Review of Systems

    Have you recently had any of these symptoms? Please check all that apply. If none of the below apply, then mark NONE.
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