Microsoft word - 3new patient questionnaire.doc

NEW PATIENT QUESTIONNAIRE

CURRENT SYMPTOMS
Please mark the location(s) of your pain with an "X" and show where it goes with an arrow.
If whole areas are painful, shade in the painful area. Circle the words which best describe you pain. Please list your complaints in order of importance.

Complaint #1
:

Do you have this pain: ( ) constantly (90-100% of the time), ( ) frequently (75%), ( ) intermittently (50%), ( ) occasionally (25%)
Pain Intensity:
“10” the most severe pain imaginable Worst pain score the last 7 days
Complaint #2
:
Do you have this pain? ( ) constantly (90-100% of the time), ( )frequently (75%), ( )intermittently (50%), ( )occasionally (25%) What makes it worse? Advanced Pain Management Institute ♦ www.PainInstitute.org ♦ 200 Butcher Road, Vacaville CA 95687 ♦ Ph: (707)359-2255 ♦ Fax: (707)359-2259 Complaint #3:
Do you have this pain: ( ) constantly (90-100% of the time), ( ) frequently (75%), ( ) intermittently (50%), ( ) occasionally (25%) What makes it worse? If you have both back and leg pain: back is ____% of entire pain If you have both neck and arm pain: neck is ____% of entire pain How many blocks can you walk before having to stop because of pain?
HISTORY OF PRESENT ILLNESS.

When did you first start having the pain? How did your symptoms start? _____ Suddenly
Are your symptoms related to an injury? NO
Where did your injury occur? (Address or description of location): When did you realize that you were injured?
The injury was

If injury was WORK RELATED: Did you report your injury to your employer/supervisor:
Please list the injured body parts, as a result of your work injury: Have you ever experienced the same or similar symptoms before this work injury? ___ Yes ___ No If yes, when? ____ / ___ / ______ (mm/dd/yyyy) Were you awarded Future Medical Benefits: Advanced Pain Management Institute ♦ www.PainInstitute.org ♦ 200 Butcher Road, Vacaville CA 95687 ♦ Ph: (707)359-2255 ♦ Fax: (707)359-2259 Are your symptoms related to a MOTOR VEHICLE ACCIDENT (MVA)? NO

Accident Information:
Date of accident?
Location of the accident: (street/city/highway/state/etc) Direction you were headed? North South East West Direction of other vehicle? North South East West Road condition: dry wet snowy icy slippery other Were you the: driver; passenger front seat back seat on driver side in the middle on passenger side Were you wearing a seat belt?
History of the Accident: Describe how the accident occurred (please
At the time of the accident were you looking?
Was your vehicle: stopped slowing down gaining speed moving at a steady speed
Estimate how fast your vehicle was traveling:
What were the year, make and model of the vehicle you were in? Year
Was the other vehicle? stopped slowing down gaining speed moving at a steady speed
Estimate how fast the other vehicle was traveling:
What were the year, make and model of the other vehicle? Year Did your vehicle collide with anything? Were you aware of the impending collision? Did you prepare yourself for the collision? NO Did any of your body parts hit the interior of the car? How many people were in your vehicle? ______ . Besides you, was anyone else injured? Any: cuts bruises scratches fractures? If yes, explain: Advanced Pain Management Institute ♦ www.PainInstitute.org ♦ 200 Butcher Road, Vacaville CA 95687 ♦ Ph: (707)359-2255 ♦ Fax: (707)359-2259 HISTORY OF TREATMENT
If injured, were you treated at the scene?
What did that doctor say was wrong with you?
Please list all the doctors seen for this injury, other than at a hospital. List in the order seen:
Name of doctor #1:
What did the doctor say was wrong with you? Name of doctor #2:
What did the doctor say was wrong with you?
Name of doctor #3:
What did the doctor say was wrong with you? Still being treated? ( )no, ( )yes If yes, how often? Any other treatment, tests, therapy or examinations that have not been described? Were you treated by any of these providers before? NO Are you using ( ) brace, ( ) cane, ( ) crutches, ( ) wheelchair? Has there been a recommendation of testing or treatment which you have not received? NO Advanced Pain Management Institute ♦ www.PainInstitute.org ♦ 200 Butcher Road, Vacaville CA 95687 ♦ Ph: (707)359-2255 ♦ Fax: (707)359-2259 DISABILITY: Has this illness affected your work performance?
Before developing this condition, how would you describe your health? Activities you avoid because of pain: ( )going to work, ( )performing household chores, ( )doing yard work or shopping, ( )driving ( )socializing , ( )participating in recreation, ( )having sexual relations, ( )exercising, ( )caring for self Have you missed work or been placed on modified duty due to this condition? NO
PRIOR WORK INJURIES: List in chronological order.
PRIOR NON-WORK RELATED INJURIES: List in chronological order.
Have you experienced the same or similar symptoms before the onset of this condition? NO Have you received a prior disability award?
If yes, did you receive a medical discharge? Have you suffered any new injuries to the body parts which were injured in the accident?
PAST MEDICAL HISTORY:
Have you ever had any of the following health problems?
Other medical problems: 1 5 2 6 3 7 List all surgeries (date and type of operation): 1. Laminectomy? Have you ever had any problems with anesthesia/sedation? NO Advanced Pain Management Institute ♦ www.PainInstitute.org ♦ 200 Butcher Road, Vacaville CA 95687 ♦ Ph: (707)359-2255 ♦ Fax: (707)359-2259
CURRENT MEDICATIONS
Please check the medications that you are currently on. Indicate the dosage and number of pills you are taking per day.
Cross out medications that you have tried in the past, indicate the reason for stopping.
NARCOTICS ANTI-INFLAMMATORIES
(NSAIDS)
ANTIDEPRESSANTS
SLEEPING PILLS
BLOOD THINNERS
ANTI-ANXIETY
MUSCLE RELAXANTS

ALLERGIES to medications (including antibiotics, local anesthetics, or materials):
latex

Review of Systems (Circle all that apply).
General
Fever Chills Unplanned weight loss Night sweats Glaucoma Double/blurred vision Blind spots Sinusitis Bleeding Congestion Runny nose Hearing loss Sore throat Difficulty swallowing Hoarseness Dentures Full/Partial Snoring Chest pain Previous heart attack Murmur Dizzy spells Congestive heart failure last six months Wheezing Shortness of breath Cough Tuberculosis Abdominal pain Heartburn Nausea Vomiting Diarrhea Constipation Incontinence Dark stools Rectal bleeding Musculoskeletal:
Knee pain Shoulder pain Restricted movement Rash Easy bruising/bleeding Lesions Abnormal hair loss Nail ridging, pitting Neurological:
Seizures Dizziness Weakness Drowsiness Trouble walking Problems controlling bowel/ bladder Psychiatric:
Difficulty falling or remaining asleep Excessive fatigue Feeling depressed Memory loss Endocrine:
Heat / cold intolerance Diabetes Thyroid disorder Hematology:
Easy bruising Low platelet count Enlarged lymph nodes Advanced Pain Management Institute ♦ www.PainInstitute.org ♦ 200 Butcher Road, Vacaville CA 95687 ♦ Ph: (707)359-2255 ♦ Fax: (707)359-2259 FAMILY HISTORY List all health problems in your family. (mom/dad/brother/sister) ( ) none

JOB DESCRIPTION
Who
When did you start working for this employer? ( ) Part-time ____ hrs/day, ____ days/week How many rest periods do you have per day? Sit __ stoop ___ walk ___ stand ___ kneel ___ squat ___ climb ___ bend ___ twist _ Please list your job duties/activities at work
WORK HISTORY Please list all previous employers before this accident. (Dates/ Employer/ Job Title/ Duties)
1.

SOCIAL HISTORY
Are you?
How many children do you have (names? ages?) Years married/ in long-term relationship
Education. How many years of schooling have you had?
partial high school (10th grade through partial 12th) partial junior high school (7th grade through 9th) If yes ________ average min/day, _________times/week Please describe your hobbies and frequency: Advanced Pain Management Institute ♦ www.PainInstitute.org ♦ 200 Butcher Road, Vacaville CA 95687 ♦ Ph: (707)359-2255 ♦ Fax: (707)359-2259
SUBSTANCE USE HISTORY


Do you use tobacco?
_____ packs of cigarettes per day for _____ years. Quit smoking ______ years ago. Used to smoke ______ packs of cigarettes per day for _____ years.
Have you ever abused alcohol?

Have you ever abused drugs?
Did you ever stop using any of the above because of dependence?
Have you ever been arrested or convicted?
Drug-related: NO YES DUI: NO
YES
Domestic violence
Have you ever had psychiatric, psychological, or social work evaluations or treatments? Advanced Pain Management Institute ♦ www.PainInstitute.org ♦ 200 Butcher Road, Vacaville CA 95687 ♦ Ph: (707)359-2255 ♦ Fax: (707)359-2259 THE OSWESTRY DISABILITY INDEX
This questionnaire has been designed to give us information as to how your back pain has affected your ability to manage everyday life activities. We realize that you may consider more than one statement in a section applicable to you but please mark the one box that most closely describes your present day situation.
1: Pain Intensity
6. Standing
0. My pain is mild to moderate. I do not need painkillers. 0. I can stand as long as I want without extra pain. 1. The pain is bad but I manage without taking painkillers. 1. I can stand as long as I want but it gives me extra pain. 2. Painkillers give complete relief from pain. 2. Pain prevents me from standing for more than 1 hour. 3. Painkillers give moderate relief from pain. 3. Pain prevents me from standing for more than ½ hour. 4. Painkillers give very little relief from pain. 4. Pain prevents me from standing for more than 10 min. 5. Painkillers have no effect on the pain. 5. Pain prevents me from standing at all. 2 Personal Care
7. Sleeping
0. I can look after myself normally without causing pain. 0. Pain does not prevent me from sleeping well. 1. I can look after myself normally but it causes extra pain. 1. I sleep well but only when taking medicine. 2. It is painful to look after myself and I am slow and careful. 2. Even when I take medication, I sleep less than 6 hours. 3. I need some help but manage most of my personal care. 3. Even when I take medication, I sleep less than 4 hours. 4. I need help every day in most aspects of self-care. 4. Even when I take medication, I sleep less than 2 hours. 5. I do not get dressed; I wash with difficulty and stay in bed. 5. Pain prevents me from sleeping at all. 3 Lifting
8. Social Life
0. I can lift heavy weights without causing extra pain. 0. My social life is normal and causes me no extra pain. 1. I can lift heavy weights but it causes extra pain. 1. My social life is normal but increased the degree of pain. 2. Pain prevents me from lifting heavy weights off the floor 2. Pain affects my social life by limiting only my more but I can manage if they are conveniently positioned (i.e. on a table) energetic interests such as dancing, sports, etc. 3. Pain prevents me from lifting heavy weights but I can 3. Pain has restricted my social life and I do not go out as manage light to medium weights if they are conveniently 4. Pain has restricted my social life to my home. 5. I have no social life because of pain. 5. I cannot lift or carry anything at all.
9. Sexual Activity
4 Walking
0. My sexual activity is normal and causes no extra pain. 1. My sexual activity is normal but causes some extra pain. 1. Pain prevents me from walking more than 1 mile. 2. My sexual activity is nearly normal but is very painful. 2. Pain prevents me from walking more than ½ mile. 3. My sexual activity is severely restricted by pain. 3. Pain prevents me from walking more than ¼ mile. 4. My sexual activity is nearly absent because of pain. 4. I can walk only if I use a cane or crutches. 5. Pain prevents any sexual activity at all. 5. I am in bed or in a chair for most of every day. 10. Traveling
5. Sitting
0. I can travel anywhere without extra pain. 0. I can sit in any chair for as long as I like. 1. I can travel anywhere but it gives me extra pain. 1. I can sit in my favorite chair only, but for as long as I like. 2. Pain is bad but I manage journeys over 2 hours. 2. Pain prevents me from sitting for more than 1 hour. 3. Pain restricts me to journeys of less than 1 hour. 3. Pain prevents me from sitting for more than ½ hour. 4. Pain restricts me to necessary journeys under ½ hour. 4. Pain prevents me from sitting for more than 10 minutes. 5. Pain prevents traveling except to the doctor/hospital 5. Pain prevents me from sitting at all. Advanced Pain Management Institute ♦ www.PainInstitute.org ♦ 200 Butcher Road, Vacaville CA 95687 ♦ Ph: (707)359-2255 ♦ Fax: (707)359-2259 BECK DEPRESSION INVENTORY
On this questionnaire are groups of statements. Please read each group of statements carefully then pick out the statement in each group that best describes the way you have been feeling the past week including today. Circle the number next to the statement you picked. If several statements in the group seem to apply equally well, circle each one. Be sure to read all the statements in each group before making your choice. 0 I have not lost interest in other people. 1 1 I am less interested in other people than I used to be. 2 I am sad all the time and I can’t snap out of it. 2 I have lost most of my interest in other people. 3 I am so sad or unhappy that I can’t stand it. 3 I have lost all of my interest in other people. 0 I am not particularly discouraged about the future 0 I make decisions about as well as I ever could. 1 I put off making decisions more than I used to. 2 I feel I have nothing to look forward to 2 I have greater difficulty in making decisions than before. 3 I feel that the future is hopeless and that things cannot improve. 3 I can’t make decisions at all anymore. 0 I don’t feel I look any worse than I used to. 1 I feel I have failed more than the average person. 1 I am worried that I am looking old or unattractive. 2 As I look back on my life, all I can see is a lot of failures. 2 I feel that there are permanent changes in my 3 I feel I am a complete failure as a person. appearance that make me look unattractive. 0 I get as much satisfaction out of things as I used to 1 I don’t enjoy things the way I used to. 2 I don’t get real satisfaction out of anything anymore. 1 It takes an extra effort to get started at doing something. 3 I am dissatisfied or bored with everything. 2 I have to push myself very hard to do anything. 2 I wake up 1-2 hours earlier than usual and find it hard 3 I wake up several hours earlier than I used to and 1 I get tired more easily than I used to. 2 I get tired for doing almost anything. 1 My appetite is not as good as it used to be. 0 I don’t feel I am any worse than anybody else. 1 I am critical of myself for my weaknesses or mistakes 2 I blame myself all the time for my faults. 3 I blame myself for everything bad that happens 0 I haven’t lost much weight, if any, lately. 1 I have lost more than 5 pounds. I am purposely trying 0 I don’t have any thoughts of killing myself 1 I have thoughts of killing myself, but I would not carry them 3 I would kill myself if I had the chance 0 I am no more worried about my health than usual. 1 I am worried about physical problems such as aches and pains, upset stomach or constipation. 2 I am very worried about physical problems and it’s 3 I used to be able to cry but now I can’t cry even though I 3 I am so worried about my physical problems that I 0 I am no more irritated now than I ever am. 0 I have not noticed any recent change in my interest in sex. 1 I get annoyed or irritated more easily than I used to. 1 1 I am less interested in sex than I used to be. 3 I don’t get irritated at all by the things that used to irritate me. 3 I have lost interest in sex completely. Advanced Pain Management Institute ♦ www.PainInstitute.org ♦ 200 Butcher Road, Vacaville CA 95687 ♦ Ph: (707)359-2255 ♦ Fax: (707)359-2259

Source: http://www.paininstitute.org/binary/org/SJM_PSP_83//3New%20Patient%20Questionnaire.pdf

Microsoft word - pubblicazioni 2008 2013

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