Pain Management History Form

  • ORA History Form

  • Today's Date:*
     - -
  • Format: (000) 000-0000.
  • Date of Birth:*
     - -

  • Present History

  • 2. When did your present problem start?
     - -
  • 3. If your problem is pain related, complete the following questions. (If not, go on to question 7.) How did the pain start?
  • 4. What activities make it worse?
  • 5. What reduces pain?
  • 6. My pain is:*
  • Worsening in that it is:

  • Where is your pain now?

  • Image field 123

  • 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.
  •
  • 7. What emotional reactions have you had to your current problem?*
  • 8. Do you have loss of bowel or bladder control?*
  • 9. My weight is:
  • 10. Problems with weak muscles, numbness, or pins & needle feeling?*
  • 11. Difficulty with sleep:

  • 12. Functional Activities - I can comfortably:

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

  • Rows
  • 13. Have you had trouble with this problem before?*
  • 14. Have you seen any doctors for your current problem?*

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

  • Rows
  • Rows
  • 18. Are you currently employed?*

  • My present job involves:

    Hours sitting
    Hours standing
    Lifting pounds

  • 19. If unemployed or not currently working:

  • Retired?
  • On Medical Leave?
  • Laid off?
  • On Total Disability?
  • Social Security Disability?
  • My employer would allow me to return to work with restrictions:

  • Past Medical History

    Do you have a history of any of the following: (Check all that apply)
  • Health History
  • Have you been diagnosed with MRSA? (Staph infection)*
  • Were you treated for MRSA?
  • Have you been diagnosed with VRE? (Vancomycin Resistant Enterococcus)*
  • Were you treated for VRE?
  • Have you had breast implant surgery?*
  • Have you had any problems related to surgery or anesthesia either before, during, or after surgery?*
  • Would you accept blood transfusions if necessary?

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

  • Allergies:

  • Allergies:*
  • Tobacco Use:*

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

  • Alcohol Use:*
  • How many drinks per week?
  • Family History: (Indicate any diseases that run your family)
  • Dominant Hand:

  • 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.
  • Constitutional*
  • Skin*
  • Eyes*
  • Ear/Nose/Throat*
  • Neuro*
  • Cardiovascular*
  • Respiratory*
  • Hematologic*
  • Mental Heath*
  • Stomach/GI*
  • Reproductive*
  • Urology*
  • Musculoskeletal*
  • Endocrine*
  • Should be Empty: