Patient History Form for Current Visit

Hudson Valley Pain Management

Patient Name

Today's Date

Date of Birth

What medical concerns can we assist with today?

On the diagram, write below the areas where you feel pain. Place an X where the pain hurts the most.

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When did your pain begin?

Which best describes your pain (check all that apply)

Sharp

Dull

Burning

Aching

Throbbing

Shooting

Constant

Intermittent

Electrical

What activities increase your pain?

Medical History (Please list all current and previous medical conditions, ex. Heart disease, diabetes, etc.)

Surgical History (Please list all previous surgeries)

Current Medications:

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Are you allergic to any medications?

Yes No

If yes, to which medications?

Social History

Do you currently smoke or chew tobacco?

Yes No

If no, have you in the past?

Yes No

How many packs per day?

Do you drink alcohol, beer, or wine?

Yes No

If no, have you in the past?

Yes No

How many drinks per week?

Do you have any history of illegal drug use?

Yes No

If yes, last time used?

Yes No

If yes, which ones?

Are you employed?

Yes No

Occupation?

Are you currently receiving or applying for disability?

Yes No

Are you currently involved in any lawsuits related to your pain?

Yes No

If yes, please explain

Family History

Do you suffer from any of the following symptoms?

Constitutional:

Eyes:

Cardiac:

Respiratory:

Gastrointestinal:

Genitourinary:

ENT:

Musculoskeletal:

Neurological:

Psychological:

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