Patient History Form

Date

Full Name

Birth Date

Age

Height

Weight

Driver License #

What's your Employment Status?

Full Time

Part Time

Retired

Homemaker

Unemployed Due to Pain

Date Last Worked

Marital Status

Married Single Divorced Widowed

# of times Married

Highest level of education

Grade School

Highschool - Grad

Voc/Tech/bus

College Degree

Date of Graduation

Occupation if Apllicable

College Degree is Apllicable

Have you Changed your Job for Health Reasons?

Yes No

What's your level of Physical Activity at work?

Highly Active Slightly Active Moderately Active Inactive

Are you pregnant or is there a chance that you could be pregnant?

Yes No

Have you or anyone in your family had a problem with an Anesthetic?

Yes No

If yes above, Please explain further

Are there any medical problems that run in the Family?

Do you Smoke?

Yes No

Do you Consume Alcohol?

Yes No

If you consider yourself disabled, please indicate the date of onset of your disability:

Sleep Pattern:

Do you Exercise?

Never Rarely Frequently

Do you have any emotional or psychological problems that concern you?

Yes No

Have you ever seen a psychologist or a psychiatrist?

Yes No

How many times have you been to the emergency room, because of the present pain?

What do you want from your treatment?

What do you expect from your treatment?

If your pain cannot be helped what do you plan to do?

List any hobbies or special interests:

Health Questionnaire

Drug Allergies

Yes No

If yes, Please List

Current medications: : what, if any, medications are you taking now. Please list all medications.

Add more Medications

Have you ever felt you had to cut down on medication?

Yes No

Have People annoyed you by criticizing your medication use?

Yes No

Have you ever felt guilty about your medication use?

Yes No

Have you ever needed an eye opener or needed medications to feel normal?

Yes No

If anything above is checked, please explain

If other surgeries please explain:

Current Medical Problems:

Pain history:

Describe in your own words what your pain is like (location, how it feels, is it consistent, does it come and go, do you have numbness, etc.)

How and when did your pain problem first start? (accident, disease, after surgery, date of onset, etc

How much work have you missed since pain onset?

Do you always have pain at rest?

Pain made better by

Rest

Sitting

Medication

Other

If other, please explain

Time of day your pain is worse

Morning, on arising

Later in morning

Afternoon

Evening

Bedtime

Night - sleeping hrs.

Pain is always the same

Pain varies - no particular time is worse

Have you had Bowel changes?

Yes No

Bladder Changes?

Yes No

Paralysis?

Yes No

Have you noticed any of the following changes in the painful area:

Increased nail growth

Skin change

Swelling

Hair growth

Sweating

Goose bumps

Temperature change

If yes to Temperature Change, Hot/Cold?

Hot Cold

Previous Treatment for pain

Nerve Blocks

Yes No

Was this treatment helpful?

Yes No

Describe Problem

Surgery

Yes No

Was this treatment Helpful?

Yes No

Describe Problem

TENS Unit

Yes No

Was this treatment helpful?

Yes No

Describe Problem

Occupational/ Physical Therapy

Yes No

Was this treatment helpful?

Yes No

Describe Problem

Biofeedback

Yes No

Was this treatment helpful?

Yes No

Describe Problem

Hypnosis

Yes No

Was this treatment helpful?

Yes No

Describe Problem

Counseling

Yes No

Was this treatment helpful?

Yes No

Describe Problem

Chiropractic

Yes No

Was this treatment helpful?

Yes No

Describe Problem

Name of Physicians involved in your medical care:

Add new row

Using the Diagram below, please click to mark *ALL* areas of the body where you feel pain. (Please note: The numbers listed in the diagram DO NOT mean that any area is more painful.)

Copy of X-ray, MRI, or Blood Work

Add file

Please upload a file

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

Patient Name

Date of Birth

Social Security Number

I acknowledge that PAIN SPECIALTY CONSULTANTS, P.A. provided me with a written copy of his/her Notice of Privacy Practices.
I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.

Patient Signature

Date of Birth

Personal Representative Signature (if applicable)

Relationship to Patient

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