proof plate: black plate: 299 - hunterdon medical center

PAIN MANAGEMENT QUESTIONNAIRE

2100 Wescott Drive, Flemington, NJ 08822

Date Soc. Sec. # Birthdate Age

Name Last Name First Name Initial

Address Home Phone Cell Phone

City State Zip

Sex: � M � F � Minor � Single � Married � Long Term Partner � Divorced � Widowed � Separated

Employer Business Phone

Business Address Occupation

Referring Physician Address Phone Number

Primary Care Physician Name: Address Phone Number

In case of emergency, who should we contact? Phone

Pharmacy Address Phone Number

Person Responsible for Account Last Name First Name Initial

Relationship to Patient Birthdate Soc. Sec.#

Address Home Phone

City State Zip

Responsible Party Employed By Business Phone

Business Address Occupation

Insurance Company

Insurance Company Address

Subscriber I.D. # Group #

Insured Name Last Name First Name Initial

Relationship to Patient Birthdate Soc. Sec.#

Address Home Phone

City State Zip

Insured Employed By Business Phone

Insurance Company

Insurance Company Address

Subscriber I.D. # Group #

I hereby authorize payment directly to all insurance benefits otherwise payable to me forservices rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, for all services rendered on my behalf or my dependents. I authorize the above noted doctor and/or any provider or supplier of services in this office to release any information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Signature of Responsible Party Date

WELCOMEWELCOME

PRIMARY INSURANCE

PATIENT REGISTRATION INFORMATION

ADDITIONAL INSURANCE (IF APPLICABLE)

ASSIGNMENT AND RELEASE

NS8120 (11/13)Name of person completing form:

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Plate: 299

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Page 2 of 14

CHIEF COMPLAINT:

1. What is the main problem for which you are seeking treatment?

PAIN QUALITY:

2. How would you describe the pain

� Burning � Sharp � Stabbing

� Cramping � Numbness � Dull

� Aching � Pressure � Soreness

� Pins and Needles � Shooting � Throbbing

� Deep � Heaviness

Other:

Name of person completing form:

PRO

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PAIN LOCATION:

3. Please describe the location of your pain

Please mark the location of your pain on the diagrams above. If whole areas are painful, please shade in the

painful area PRO

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Page 4 of 14

DURATION:

4. How long have you had your current pain problem

Years Months

ONSET OF PAIN:

5. How did your current pain start?

� Injury at work

� Treatment caused (eg: Radiation, surgery etc.)

� Injury not at work

� Motor Vehicle Accident

� Illness/ Non Injury

� Undetermined

� Other

� Please describe

6. In general during the past month, has your pain been? (check one)

� Better � Worse � The same

TIMING OF PAIN:

7. How often do you have your pain?

� Constantly (100% of the time)

� Frequently (75% of the time)

� Intermittently (50% of the time)

� Occasionally (25% of the time)PRO

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ACTIVITIES AND YOUR PAIN:8. Does your pain interfere with any of the following? (check all that apply) � Sleep � Daily activities � Work � Relationships Does your pain make you feel: � Depressed � Angry � Frustrated � Helpless/hopeless

9. Does your pain cause any of the following? � Loss of bowel control? � Loss of bladder control?

10. Pain intensity and interference:In the last month, on average, how would you rate your pain? Use a scale from 0 to 10, where 0 is “no pain” and 10 is “pain as bad as could be”? [That is, your usual pain at times you were in pain.] No Pain as bad as pain could be 0 1 2 3 4 5 6 7 8 9 10

In the last month, how much pain interfered with your daily activities? Use a scale form 0 to 10, where 0 is “no interference” and 10 is “unable to carry on any activities”? No Unable to carry on interference any activities 0 1 2 3 4 5 6 7 8 9 10

AGGRAVATING AND RELIEVING FACTORS:11. How do the following affect your pain? (please check one for each item)

Decrease No change IncreaseLying downStandingSittingWalkingBendingChanging positionsExerciseMedicationsRelaxationThinking about something elseCoughing/SneezingUrinationBowel movementsPR

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PRIOR CONSULTATIONS:

12. Which physicians have you seen for your current condition? Please state name

� Primary care physician:

� Neurosurgeon:

� Neurologist:

� Physiatrist:

� Orthopedic surgeon:

� Pain Management:

� Psychiatrist: Psychologist:

13. What DIAGNOSTIC STUDIES have you had?

MRI

� A. Back Date:

� B. Neck Date:

CT Scan

� A. Back Date:

� B. Neck Date:

� EMG Date:

� Xrays Date:

� Other: Date:

� Myelogram Date:

� Bone Scan Date:

� Blood Tests Date:PRO

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Page 7 of 14

TREATMENT:14. Please check all the treatments you have applied for your pain and then complete the appropriate

column on the right to the best of your ability

Treatment Date(approximate) No Relief Moderate Relief Excellent Relief

Bed Rest

Traction

Surgery

Hypnosis

Acupuncture

Nerve Block or Injections

TENS

Physical Therapy

Exercise

Biofeedback

Psychotherapy

Chiropractic

Ice or Heat

Herbal Remedies

Other

MEDICATIONS:

15. Please list your current medications with dosages

PRO

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MEDICATIONS (continued):

16. Please list any previously taken pain medications that you stopped taking and reasons for stopping

ALLERGIES:

17. Contrast dye

Other medications or foods? Please list reaction

PRIOR MEDICAL HISTORY:

18. Have you had any of the following health problems?

(please check all that apply)

� High blood pressure � Diabetes or high blood sugar

� High cholesterol � Pacemaker � Defibrillator

� Heart murmurs � Heart Attack / Chest Pain / Angina

� Asthma or wheezing � Chronic cough

� Sleep Apnea � Seizure or epilepsy

� TIA or stroke � Heartburn

� Kidney disease � Liver disease/ Hepatitis

� Arthritis � Bleeding problem

� HIV � Aneurysm

� Circulation Problem

� Fibromyalgia

� Cancer, please specify what type

� Other, please specify PRO

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19. PAST SURGICAL HISTORYDate (approximate) Hospital Type of Operation

20. FAMILY HISTORY: Do any of the below family members have any medical problems?

Mother

Father

Siblings

Other

21. REVIEW OF SYSTEMS:

CONSTITUTIONAL CARDIOVASCULAR GASTROINTESTINAL

� Weight gain � Heart trouble � Nausea

� Weight loss � Chest Pain � Diarrhea

� (>10 lbs/6months) � Heart murmur � Constipation

� Loss of Appetite � Palpitations � Abdominal Pain

� Insomnia � Varicose veins � Blood in stool

� Fever/Chills � Fainting spells � Hepatitis

� Fatigue � Swelling of ankles � Reflux/Heartburn

� No Issues � Normal � Normal PRO

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21. REVIEW OF SYSTEMS (continued): EYES RESPIRATORY HEMATOLOGIC � Eye Disease � Shortness of Breath � Bleeding tendency � Glaucoma � Chronic Cough � Anemia � Glasses/contacts � Wheezing � Recurrent Infection � Blurry vision � Asthma SKIN � Vision loss � Cold/infection � Rash or itching � Normal � Sleep Apnea � Change in skin color � Home oxygen � Change in hair or nails � Normal � Normal NEUROLOGIC GENITOURINARY EAR/NOSE/MOUTH � Frequent Headaches � Frequent urination � Hearing Loss � Light headed/dizzy � Urinary Urgency � Ringing in ears � Convulsions/seizures � Painful urination � Sinus Problems � Numbness/tingling � Incontinence � Nose Bleeds � Tremors � Sexual difficulty � Mouth Sores � Paralysis � Kidney stones � Swollen neck glands � Head Injury � Catheter � Normal � Memory Loss � Normal � Normal PSYCHIATRIC MUSCULOSKELETAL ENDOCRINE � Anxiety � Joint Pain � Excessive thirst � Depression � Joint Swelling � Heat/cold intolerance � Hallucinations � Weakness � Hormone problems � Mental Illness � Muscle cramps � Normal � Normal � Back Pain � Difficulty walking � Normal Is there any chance you could be pregnant? � No / � Yes

22. Do you have any implanted devices? � Screws, Pins, plates � AICD � Aneurysm Clip � IUD � Pacemaker

23. Do you have a history of passing out with needles or medical procedures? PR

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Page 11 of 14

EMPLOYMENT:

24. � Your highest education level achieved?

Your Current or former occupation

Who is your current employer?

If you are currently unemployed, indicated how long you have been out of work

LEGAL ISSUES:

25. Please indicate any of the following claims you have filed related to your pain

� Worker's compensation

� Personal Injury/ Liability (unrelated to work)

� Social Security Disability Insurance (SSDI)

� Other LEGAL CLAIMS

� None

ATTORNEY'S NAME AND CONTACT INFORMATION

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PSYCHOLOGICAL TREATMENT: Mark each box that applies

26. Family History of Substance Abuse? Alcohol � Illegal Drugs � Prescription Drugs �

27. Personal History of Substance Abuse? Alcohol � Illegal Drugs � Prescription Drugs �

28. Age (Mark box if 16-45) �

29. History of Preadolescent Sexual Abuse �

30. Psychological Disease Attention Deficit Disorder � Obsessive Compulsive Disorder � Bipolar � Schizophrenia � Depression �

Have you ever attempted suicide? � No / � Yes

If yes, when

Do you currently have suicidal thoughts? � No / � Yes

31. SUBSTANCE USE: Do you smoke? � No / � Yes

If yes, how many packs per day?

How many years have you smoked?

If you used to smoke, how long ago did you quit?

Do you drink alcohol? � No / � Yes

If yes, how much

Do you use recreational drugs? � No / � Yes

If yes, please describe PRO

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31. SUBSTANCE USE (continued): Did you ever use recreational drugs? � No / � Yes

If so, please describe

Have you ever been in a detoxification program for drug abuse? � No / � Yes

Alcoholics Anonymous? � No / � Yes

Narcotics Anonymous? � No / � Yes

Have you ever felt that you ought to cut down on your drinking or drug use? � No / � Yes

Have people annoyed you by criticizing your drinking or drug use? � No / � Yes

Have you ever felt bad or guilty about your drinking or drug use? � No / � Yes

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? � No / � Yes

FAMILY LIFE:

32. "I currently am"

� Living alone

� Living with friends

� Living with children

� Living with spouse/partner

� Living with spouse/partner and children

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SYMPTOM CHECKLIST:

33. Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully, and check your response.

Not at all

Several days

More than half the days

Nearly every day

0 1 2 3

a. Little interest or pleasure in doing things

b. Feeling down, depressed or hopeless

c. Trouble falling asleep, staying asleep, or sleeping too much

d. Feeling tired or having little energy

e. Poor appetite or overeating

f. Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down

g. Trouble concentrating on things such as reading the newspaper or watching television

h. Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual

i. Thinking that you would be better off dead or that you want to hurt your self in some way

Totals

33. If you have checked off any problem on this questionnaire so far, 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

0 1 2 3PRO

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proof plate: black plate: 299 - hunterdon medical center

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