Dr. Olinka Hrebicek, Neurology
Pain Intake Form
Full Name
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Email
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example@example.com
Phone Number
Please enter a valid phone number.
Primary Care Provider
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Preferred pharmacy name and location
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Age
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Height
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Weight
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Handedness
*
Please Select
Left
Right
Current/past occupation
Describe your living situation (check all that apply):
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Live alone
Live with other(s)
Spouse
Children at home
Other
CURRENT NEUROLOGICAL CONCERNS: Why are you here today?
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When did the problem start?
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Conditions/illnesses you have or have had (check all that apply). Add notes below if necessary:
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ADHD
Anxiety
Autism
Bleeding Tendency
Blood Clots
Cancer
Depression
Diabetes
Drug Addiction*
Glaucoma
Head Injuries
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
HIV
Hypothyroidism
IBD/Crohn's Disease
Jaundice
Kidney Disease
Lupus
Migraine Headaches
Peptic Ulcer Disease
Pneumonia
Sleep Apnea
STI*
Stroke
Tuberculosis
Other
Notes about checked conditions/illnesses:
How many alcoholic drinks do you consume in a week?
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Have you quit previously?
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Yes
No
Do you smoke?
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Please Select
Yes
No
If you have quit smoking, when?
Recreational Drug Use:
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Please Select
Never
Now
In the Past
If you used in the past, when?
Previous Injuries
List all prescription medications (including dosage details) you currently take:
List any over-the-counter drugs, supplements, herbs or vitamins you currently take:
List medication allergies and reactions (ie. rash) you have had:
List medication allergies and reactions (ie. rash) you have had:
List any significant diseases that run in your family (ie. diabetes, strokes, migraines, neurological diseases):
Review of Symptoms
Cardiovascular
Musculoskeletal
Skin
Gastrointestinal
Genitourinary
Neurologic
Eyes
Respiratory
ENT
Constitutional
Hematologic
Headache Questionnaire
Length of time you have suffered from headaches:
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Headache Duration:
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Please Select
less than 2 hours
2-72 hours
over 72 hours
Frequency (headaches per month)
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Please Select
less than 2
less than 4
less than 8
less than 16
more than 16
Site of Pain
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Please Select
One Side
Both Sides
Beginning on one side and spreading to the other
Type of Pain
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Severity of Pain
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Please Select
Mild
Moderate
Severe
Is the pain aggravated by routine physical activity?
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Yes
No
How many days in the last month did you have a headache?
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Other Symptoms
Nausea
Vomiting
Sensitivity to light
Sensitivity to smell
Sensitivity to sound
Aura (ie. Flashes of light or blurred vision or 'zig-zag' patterns
On a scale of 0-10, on average how painful were these headaches? (0=no pain at all and 10=pain as bad as it can be)
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Have you defined any migraine triggers?
Preventative agents you have tried:
Betablocker (such as Propranolol, Nadolol, Metroporlol or Atenolol)z
Divalproex sodium (Epival) Valproic Acid (Depakene)
Duloxetine (Cymbalta)
Gabapentin (Neurontin)
Nortriptyline, Amitriptyline
Sandomigran
Topiramate (Topomax)
Venlafaxine (Effexor)
Verapamil, Flunarizine (Sibelium)
Other
Abortive agents you have tried:
Acetaminophen (Tylenol)
Almotriptan (Axert)
Diclofenac Potassium Powder (Cambia)
Eletriptan (Relpax)
Frovatriptan (Frova)
Naratriptan (Amerge)
Rimegepant (Nurtec ODT)
Rizatriptan (Maxalt)
Sumatriptan (Imitrex)
Sumatriptan/Naproxen Sodium (Suvexx)
Ubrogepant (Ubrelvy)
Zolmitriptan (Zomig)
Non-steroid anti-inflammatory medication – (i.e., Naproxen)
Other
CGRP antagonists you have tried:
Atogepant (Qulipta)
Eptinezumab (Vyepti)
Erenumab (Aimovig)
Fremanezumab (Ajovy)
Galcanezumab (Emgality)
Other
Non-pharmacological treatments you have tried:
Acupuncture
Chiropractic Therapy
Massage
Physiotherapy
Other
Pain and Function Assessment Questionnaire
Primary Diagnosis
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Medications for Pain
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Duration of Pain
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Do you think that the doctors and nurses understand your pain?
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Yes
No
Location of Pain: Mark on drawing.
Quality of Pain: Describe how the pain feels
Intensity of Pain: Rate the pain on a 0-5 scale (0=No Pain, 5=Worst Pain)
Duration of Pain: After the pain comes on, for what length of time does it last?
Trigger Factors: What makes the pain worse? (Consider posture, movement, eating, for example.)
Relieving Factors: What makes the pain better? (Consider posture, movement, eating, for example.)
Effects of Pain: Any associated symptoms with the pain?
Nausea
Depression
Constipation
Anxiety
Other
Is the pain preventing you from doing what you would like to do? Explain.
PHQ-9 Nine Symptom Checklist
1) Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
2) Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
3) Trouble falling or staying asleep, or sleeping too much
Not at all
Several days
More than half the days
Nearly every day
4) Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly every day
5) Poor appetite or overeating
Not at all
Several days
More than half the days
Nearly every day
6) Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Not at all
Several days
More than half the days
Nearly every day
7) Trouble concentrating on things, such as reading the newspaper or watching television
Not at all
Several days
More than half the days
Nearly every day
8) Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
Not at all
Several days
More than half the days
Nearly every day
9) Thoughts that you would be better off dead or hurting yourself in some way
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
Not at all
Several days
More than half the days
Nearly every day
If you checked off ANY problems, how DIFFICULT have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
PHQ-9 Score
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
TOTAL
Score
GAD-7 Screening Questions
1) Feeling nervous, anxious, or on edge
Not at all
Several days
More than half the days
Nearly every day
2) Not being able to stop or control worrying
Not at all
Several days
More than half the days
Nearly every day
3) Worrying too much about different things
Not at all
Several days
More than half the days
Nearly every day
4) Trouble relaxing
Not at all
Several days
More than half the days
Nearly every day
5) Being so restless that it is hard to sit still
Not at all
Several days
More than half the days
Nearly every day
6) Becoming easily annoyed or irritable
Not at all
Several days
More than half the days
Nearly every day
7) Feeling afraid, as if something awful might happen
Not at all
Several days
More than half the days
Nearly every day
If you checked off ANY problems, how DIFFICULT have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
GAD-7 Score
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
TOTAL
Score
Interactions between Dr. Hrebicek, office staff and patients should always be professional, respectful and courteous. If I am unable to meet this expectation, I understand that it may affect my ability to continue as a patient in this practice.
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I understand
I understand that there may be a fee for certain services performed by the doctor. (Ie. Completing insurance forms or other tasks, according to the Doctors of BC Fees for Uninsured Services.)
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I understand
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