Pain Intake Form

Pain Intake Form - Appointment Date:
Dr. Olinka Hrebicek, Neurology

Pain Intake Form
Full Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Provider
Preferred pharmacy name and location
Age
Height
Weight
Handedness
Current/past occupation
Describe your living situation (check all that apply):

Other
CURRENT NEUROLOGICAL CONCERNS: Why are you here today?
When did the problem start?
Conditions/illnesses you have or have had (check all that apply). Add notes below if necessary:

Other
Notes about checked conditions/illnesses:
How many alcoholic drinks do you consume in a week?
Have you quit previously?
Do you smoke?
If you have quit smoking, when?
Recreational Drug Use:
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:
Do you have any medication allergies?
List medication allergies and reactions (ie. rash) you have had:
List medication allergies and reactions (ie. rash) you have had:
Do you have extended benefit coverage?

Yes
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:
Headache Duration:
Frequency (headaches per month)
Site of Pain
Type of Pain
Severity of Pain
Is the pain aggravated by routine physical activity?
How many days in the last month did you have a headache?
Other Symptoms
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)
Have you defined any migraine triggers?
Preventative agents you have tried:

Other
Abortive agents you have tried:

Other
CGRP antagonists you have tried:

Other
Non-pharmacological treatments you have tried:

Other
Pain and Function Assessment Questionnaire
Primary Diagnosis
Medications for Pain
Duration of Pain
Do you think that the doctors and nurses understand your pain?
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?

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
2) Feeling down, depressed, or hopeless
3) Trouble falling or staying asleep, or sleeping too much
4) Feeling tired or having little energy
5) Poor appetite or overeating
6) Feeling bad about yourself - or that you are a failure or have let yourself or your family down
7) Trouble concentrating on things, such as reading the newspaper or watching television
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
9) Thoughts that you would be better off dead or hurting yourself in some way
Trouble concentrating on things, such as reading the newspaper or watching television
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?

PHQ-9 Score

Rows	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
2) Not being able to stop or control worrying
3) Worrying too much about different things
4) Trouble relaxing
5) Being so restless that it is hard to sit still
6) Becoming easily annoyed or irritable
7) Feeling afraid, as if something awful might happen
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?

GAD-7 Score

Rows	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.
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.)
Should be Empty:

Dr. Olinka Hrebicek, Neurology

Review of Symptoms

Headache Questionnaire

Pain and Function Assessment Questionnaire

PHQ-9 Nine Symptom Checklist

GAD-7 Screening Questions