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QUESTIONNAIRE Pain Management Center

*4-16560* FORM 4-16560 REV. 12/2012 Page 1 of 11

PATIENT INFORMATION Appointment: Date ____________ Time __________ Name ________________________________________

Date of Birth _________________ Age ____________ � Male � Female

Address ________________________________________________ City / Zip ________________________

Home Phone ___________________ Cell Phone ___________________ Other Phone __________________

Name of physician who referred you ______________________________ Phone _______________________

Name of your primary care physician ______________________________ Phone ______________________

List all physicians you currently see ___________________________________________________________

________________________________________________________________________________________

Allergies _________________________________________________________________________________

________________________________________________________________________________________

MEDICAL HISTORY Check any of the following conditions you have had or currently have (include dates if possible) � Diabetes _ � Cancer/Type _ � Thyroid problems _ � Respiratory disease/emphysema _ � Obstructive sleep apnea _ � High blood pressure _ � Neurological disease _ � Bleeding disorder _ � Arthritis _ � Ulcer/gastrointestinal disease _ � Kidney problems _ � Narcolepsy _ � Infectious disease/HIV/TB _ � Liver disease/hepatitis _ � Stroke _ � Heart problem/heart attacks/heart surgery _ � Autoimmune disorders (lupus, rheumatoid arthritis, scleroderma) _ � Other condition(s) not listed _ SURGICAL HISTORY List any past surgeries or procedures (Include approximate dates and the surgeon/ physician’s name) _ _ _ _ _ _ _

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QUESTIONNAIRE Pain Management Center

FORM 4-16560 REV. 12/2012 Page 2 of 11

REVIEW OF SYSTEMS (Check all that apply) Constitutional Symptoms Genitourinary Good general health � Yes Increased or decreased urination � Yes Recent weight change � Yes Difficulty in starting urination � Yes Fever � Yes Difficulty controlling urination � Yes Headaches � Yes Rashes � Yes Gastrointestinal Loss of appetite � Yes Musculoskeletal Change in bowel habits � Yes Joint pain � Yes Nausea and/or vomiting � Yes Joint stiffness or swelling � Yes Frequent diarrhea � Yes Weakness of muscles or joints � Yes Rectal bleeding/blood in stool � Yes Black, tarry stools � Yes Respiratory Shortness of breath � Yes Cardiac Wheezing � Yes Fluttering/palpitations of the heart � Yes Poor exercise tolerance � Yes Irregular heartbeat � Yes Frequent cough � Yes Chest pain or pressure � Yes Night sweats � Yes Swelling of the feet or ankles � Yes Neurologic Endocrine Weakness in limbs � Yes Thirsty all the time � Yes Difficulty with balance � Yes Cold most of the time � Yes Dizzy or fainting spells � Yes Too warm most of the time � Yes Speech difficulty � Yes Unusually tired or sluggish � Yes Seizures � Yes Unusually jumpy or nervous � Yes Obstructive Sleep Apnea Female reproductive Wake up with dry, sore throat frequently � Yes Changes in periods � Yes Loud Snoring � Yes Irregular periods � Yes Wake up choking or gasping for air � Yes Vaginal discharge � Yes Sleepienss, lack of energy in the daytime � Yes Pain with intercourse � Yes Sleepiness while driving � Yes Abnormal vaginal bleeding � Yes Morning headaches � Yes Hot flashes � Yes Restless sleep � Yes Forgetfulness and or mood changes � Yes Male reproductive Recurrent wakenings or insomnia � Yes Decrease libido (sex drive) � Yes Decrease in strength or endurance � Yes Loss in height � Yes Decreased enjoyment in life � Yes Sad and or grumpy � Yes Are you erections less strong � Yes Decreased ability to play sports � Yes Falling asleep after dinner � Yes Decreased work performance � Yes

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QUESTIONNAIRE Pain Management Center

FORM 4-16560 REV. 12/2012 Page 3 of 11

PSYCHOLOGICAL HISTORY

1. List any past or current psychological problems, including depression, that have required medical treatment or hospitalization. If yes, please list dates, location of treatment and physician.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

2. Have you ever abused drugs, alcohol or other substances (currently or in the past)? � Yes � No

If yes, please list them ____________________________________________________________________________________

____________________________________________________________________________________

3. Have you ever been hospitalized or treated for a substance abuse problem? � Yes � No

If yes, please list dates, location of treatments, and physician ____________________________________________________________________________________

____________________________________________________________________________________

4. Who/What do you turn to in stressful times? ____________________________________________________________________________________

____________________________________________________________________________________

5. How would you describe your current level of stress? � Low � Medium � High � Extreme

6. What are the main causes of stress in your life? ____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

7. Have you ever attempted or seriously considered suicide? � Yes � No

____________________________________________________________________________________

SOCIAL HISTORY

1. What is your living status? � Single � Married � Co-habitating � Divorced � Widowed � Separated

2. Who currently lives with you? ___________________________________________________________

3. Has your living status changed since your pain began? ______________________________________

4. Are you currently working? � Full-time � Part-time � Retired � Disabled � Not working � Student

5. If you are working, describe your job _____________________________________________________

6. Has your work status or occupation changed because of your pain? � Yes � No

7. Are you receiving Workers Compensation or disability benefits? �Yes � No

8. What is the highest level of education you have completed? ___________________________________

9. Do you use tobacco in any form? � Yes � No

If yes, what kind? __________________ How much per day? __________ For how long? __________

10. Do you drink alcoholic beverages? � Yes � No If yes, what kind? � Beer � Liquor � Wine

11. Do you drink any beverages containing caffeine? � Yes � No

If yes, what kind and how many per day? � Coffee __________ � Tea ________ � Sodas _________

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QUESTIONNAIRE Pain Management Center

FORM 4-16560 REV. 12/2012 Page 4 of 11

The following are some questions given to all patients at the Pain Management Center who are on or being considered for opioids for their pain. Please answer each question as honestly as possible. This information is for our records and will remain confidential. Your answers alone will not determine your treatment.

1. Have you ever felt that you should cut down on your drinking or pain medication?

DO NOT answer next 3 questions if you have NEVER had a drink or taken pain medication

� Yes � No

2. 3.

Have people criticized your drinking or taking pain medication? Have you ever felt bad or guilty about your drinking or taking pain medication?

� Yes � No � Yes � No

4. Have you ever had a drink first thing in the morning or a drink to get rid of a hangover (eye-opener)?

� Yes � No

ANSWER THE QUESTIONS BELOW USING THE FOLLOWING SCALE: 0 = Never 1 = Seldom 2 = Sometimes 3 = Often 4 = Very Often Circle one_ 1. How often do you have mood swings? 0 1 2 3 4 2. How often do you smoke a cigarette within an hour after you wake up? 0 1 2 3 4 3. How often have any of your family members, including parents and grandparents, had a

problem with alcohol or drugs? 0 1 2 3 4

4. How often have any of your close friends had a problem with alcohol or drugs? 0 1 2 3 4 5. How often have others suggested that you have a drug or alcohol problem? 0 1 2 3 4 6. How often have you attended an AA or NA meeting? 0 1 2 3 4 7. How often have you taken medication other than the way that it was prescribed? 0 1 2 3 4 8. How often have you been treated for an alcohol or drug problem? 0 1 2 3 4 9. How often have your medications been lost or stolen? 0 1 2 3 4 10. How often have others expressed concern over your use of medication? 0 1 2 3 4 11. How often have you felt a craving for medication? 0 1 2 3 4 12. How often have you been asked to give a urine screen for substance abuse? 0 1 2 3 4 13. How often have you used illegal drugs (for example, marijuana, cocaine, etc.) in the past

five years? 0 1 2 3 4

14. How often have you had legal problems or been arrested? 0 1 2 3 4

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QUESTIONNAIRE Pain Management Center

FORM 4-16560 REV. 12/2012 Page 5 of 11

PAIN HISTORY 1. When did your problems with pain first begin? _________________________________________________________

______________________________________________________________________________________________ ______________________________________________________________________________________________ 2.

How did your pain first begin? (accident, job related, fall, etc.)? ____________________________________________

______________________________________________________________________________________________ 3.

Describe your pain problem. _______________________________________________________________________

______________________________________________________________________________________________ ______________________________________________________________________________________________ 4.

Describe the pattern of your pain. (when it is worse, is it constant, intermittent, etc.)____________________________ ______________________________________________________________________________________________

5. 6.

Do you feel that treatment can help you? � Yes � No � Unsure What are your goals for the treatment of your pain?_____________________________________________________

______________________________________________________________________________________________ 7.

Have you ever been hospitalized for treatment of your pain? � Yes � No

If yes, explain___________________________________________________________________________________ ______________________________________________________________________________________________ 8.

Estimate the number of visits to doctors or clinics for your pain problem in the past year ________________________

9.

Have you ever been treated by another pain clinic in the past? � Yes � No

If yes, list the clinic, dates and doctors:_______________________________________________________________ ______________________________________________________________________________________________

10. Are you currently being treated at another pain clinic? � Yes � No If yes, list the clinic, dates and doctors:_______________________________________________________________

______________________________________________________________________________________________ ______________________________________________________________________________________________ 11.

Are you involved in any legal action regarding your pain problem? � Yes � No

If yes, describe the status and type of legal action ______________________________________________________ ______________________________________________________________________________________________ 12.

Are you considering legal action regarding your pain problem in the near future? � Yes � No

13.

How would you describe your pain?

� dull � sharp � shooting � heavy � aching � tender � burning � other_________________________ 14.

Circle the levels of your pain from for the following:

0=no pain to 10=worst pain imaginable

Present level of pain 0 1 2 3 4 5 6 7 8 9 10

Average level of pain 0 1 2 3 4 5 6 7 8 9 10

Least level of pain 0 1 2 3 4 5 6 7 8 9 10

Worst level of pain 0 1 2 3 4 5 6 7 8 9 10

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QUESTIONNAIRE Pain Management Center

FORM 4-16560 REV. 12/2012 Page 6 of 11

15. Please shade in any area where you feel pain or numbness.

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QUESTIONNAIRE Pain Management Center

FORM 4-16560 REV. 12/2012 Page 7 of 11

16. How is your pain affected by the following activities? Relieves Pain Worsens Pain No Change in Pain Laying down � � � Sitting � � � Standing � � � Bending � � � Lifting � � � Exercise � � � Heat pack Ice pack

�

�

�

�

�

�

Hot weather Wet weather

�

�

�

�

�

�

Cold weather � � � Eating � � � Urination � � � Bowel movement � � � Sexual activity � � � Menstrual cycle � � � Walking � � � Stairs � � � Emotional stress � � � Noise Massage

�

�

�

�

�

�

17.

Other (non medicine) _________________________________________________________________ How many days in a month do you have pain? _____________________________________________

18. How many hours of the day do you have pain? _____________________________________________ 19. How long are you able to sit before you become uncomfortable? _______________________________ 20. How long are you able to stand before you become uncomfortable?_____________________________ 21. How far are you able to walk before becoming uncomfortable?_________________________________ 22. In your daily activities, how much weight can you lift comfortably? ______________________________ 23. Circle the number that describes how your pain has interfered with these activities

0 = does not interfere to 10 = completely interferes

Sleep 0 1 2 3 4 5 6 7 8 9 10

Appetite 0 1 2 3 4 5 6 7 8 9 10

Relationships 0 1 2 3 4 5 6 7 8 9 10

Work 0 1 2 3 4 5 6 7 8 9 10

Finances 0 1 2 3 4 5 6 7 8 9 10

Physical activity 0 1 2 3 4 5 6 7 8 9 10

Emotions 0 1 2 3 4 5 6 7 8 9 10

Concentration 0 1 2 3 4 5 6 7 8 9 10

24. Feel free to offer any other comments on the above scale ____________________________________

__________________________________________________________________________________ __________________________________________________________________________________

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QUESTIONNAIRE Pain Management Center

FORM 4-16560 REV. 12/2012 Page 8 of 11

25. What treatments have you received for the management for your pain?

Helpful Not Helpful Dates Surgery � � ____________________________Nerve Block � � ____________________________Steroid Injection � � ____________________________Trigger Point Injections � � ____________________________TENS Unit � � ____________________________Neuromuscular Stimulator � � ____________________________Dorsal Horn Stimulator � � ____________________________Physical Therapy � � ____________________________Occupational Therapy � � ____________________________Counseling � � ____________________________Acupuncture � � ____________________________Chiropractic � � ____________________________Homeopathy � � ____________________________Massage Therapy � � ____________________________Herbal / Natural Remedies � � ____________________________Any Implanted Device or Pump � � ____________________________Other treatment _________________ � � __________________________________________________________ � � ____________________________

26. What best describes your present use of pain medication?

� Definitely increasing � Slightly increasing � Same as always � Definitely decreasing � Slightly decreasing � Not applicable

27. Do you perform excersises or stretching as prescribed by a doctor or therapist? �Yes �No If yes, how many minutes a day _____________ and how many times a week _____________

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QUESTIONNAIRE Pain Management Center

FORM 4-16560 REV. 12/2012 Page 9 of 11

Check any medications you have used. List if they helped or you had problems. Look for the medication name, not the category where it is listed.

Opioids (Narcotics)

� Buprenorphine (Buprenex, Butrans, Suboxone, Subutex)

� Butorphanol (Stadol) � Codeine Sulfate (Tylenol with

Codeine)

� Fentanyl (Abstral, Actiq, Duragesic, Fentora, Lazanda, Onsolis, Subsys)

� Hydrocodone (Hycet, Lorcet, Lortab, Maxidone, Norco, Vicodan, Vicoprofen)

� Hydromorphone (Dilaudid, Exalgo)

� Methadone (Dolophine, Methadose)

� Meperidine (Demerol) � Morphine Sulfate (Avinza,

Kadian, MS Contin, Oramorph SR, Roxanol,MSIR)

� Nalbuphine (Nubain) � Oxycodone (Combunox,

Endocet, Oxecta, Oxycontin, Oxyfast, Percocet, Percodan, Roxicodone, Roxicet, Tylox)

� Oxymorphine (Opana, Opana ER)

� Pentazocine (Talwin) � Propoxyhene (Darvon,

Darvocet)

� Tapentadol (Nycynta, Nucynta ER)

� Tramadol (Ryzolt, Rybix ODT, Ultram, Ultracet)

� Other

Acetaminophen & Salicylates

� Acetaminophen (Tylenol) � Acetaminophen/Asprin

(Excedrin, Goody Powder)

� Asprin (Anacin, Bayer, BC Powder, Ecotrin)

� Choline Magnesium Trisalicylate (Trilisate)

� Magnesium Salicylate (Percogesic)

� Other

Muscle Relaxants

Baclofen (Lioresal) � Carisoprodol (Soma) � Chlorzoxazone (Lorzone,

Parafon Forte)

� Cyclobenzaprine (Amrix, Fexmid, Flexaril)

� Diazepam (Valium) � Metaxalone (Skelaxin) � Methocarbamol (Robaxin) � Orphenadrine (Norflex) � Tizanidine (Zanaflex) � Other

Anti-Anxiety

� Alprazolam (Xanax) � Buspirone (Buspar) � Clorazepate (Tranxene) � Clonazepam (Klonopin) � Diazepam (Valium) � Hydroxyzine (Atarax, Vistraril) � Lorazepam (Ativan) � Oxazepam (Serax) � Other

Other Analgesics

� Acetaminophen, Isometheptene, Dichloratphenazone (Midrin)

� Butalbital (Fioricet, Fiorinal) � Butorphanol (Stadol NS) � Dihydroergotamine

(D.H.E.45)

� Eletriptan (Replax) � Ergotamine (Cafergot) � Rizatriptan (Maxalt) � Sumatriptan (Imitrex,

Treximet)

Topical Analgesics

� Capsaicin (Zostrix, Capsaicin, Qutenza)

� Dicofenac (Flector patch, Pennsaid, Voltaren gel)

� Lidocaine (Lidoderm) � Methylsalicylate or Menthol

(Bengay, Flexall, Icy Hot, Salonpas, Tylenol Precise)

� Other

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QUESTIONNAIRE Pain Management Center

FORM 4-16560 REV. 12/2012 Page 10 of 11

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

� Celecoxib (Celebrex) � Diclofenac (Arthrotec,

Cambia, Flector patch, Pennsaid, Voltaren, Voltaren gel)

� Diflunisal (Dolobid) � Etodolac (Lodine) � Fenoprofen (Nalfon) � Flurbiprofen (Ansaid) � Ibuprofen (Advil, Motrin) � Indomethacin (Indocin) � Ketoprofen (Orudis) � Ketorolac (Toradol) � Meclofenamate (Meclomen) � Mefenamic Acid (Ponstel) � Meloxicam (Mobic) � Nabumetone (Relafen) � Naproxen (Aleve, Anaprox,

Naprelan, Naprosyn, Vimovo)

� Oxaprozin (Daypro) � Piroxicam (Feldene) � Sulindac (Clinoril) � Other

Anti-Depressants

� Amitriptyline (Elavil) � Aripiprazole (Abilify) � Bupropion (Wellbutrin) � Citalopram (Celexa) � Desipramine (Norpramin) � Desvenlafaxine (Pristiq) � Duloxetine (Cymbalta) � Escitalopram (Lexapro) � Fluoxetine (Prozac) � Imipramine (Tofranil) � Mirtazapine (Remeron) � Nortiptyline (Pamelor) � Paroxetine (Paxil) � Sertraline (Zoloft) � Venlafaxine (Effexor) � Other

Insomnia

� Doxepin (Sinequan) � Eszopiclone (Lunesta) � Flurazepam (Dalmane) � Gabapentin (Neurontin) � Milnacipran (Savella) � Pregabalin (Lyrica) � Ramelteon (Rozeram) � Temazepam (Restoril) � Tiagabine (Gabatril) � Topiramate (Topamax) � Trazadone (Desyrel) � Zaleplon (Sonata) � Zolpidem (Ambien) � Zolmitriptan (Zomig) � Other

Please list any supplements or herbal medications you have taken to relieve pain: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________

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QUESTIONNAIRE Pain Management Center

FORM 4-16560 REV. 12/2012 Page 11 of 11

28. List any radiology procedures performed in the last two years: Test Body Part Date Facility Ordering Physician

� Plain X-Ray _______________________________________________________________________

� MRI __________________ __________________________ ______________________

� CT Scan ______________________________________________ ______________________

� EMG ______________________________________________ ______________________

� Myelogram ______________________________________________ ______________________

� Other ________________ ______________________________________________ ______________________

� Other ________________ ______________________________________________ ______________________

29. If you have several areas that are painful – rank them from worst to least pain

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________

3. ____________________________________________________________________________________

4. ____________________________________________________________________________________

5. ____________________________________________________________________________________

6. ____________________________________________________________________________________

30. Is there anything else that you can think of that might help us with your pain management?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Patient’s Signature __________________________________________________ Date _________________

Patient is unable to sign due to the following reason ______________________________________________

Representative’s Signature ___________________________________________ Date _________________

Representative’s Name (print) ____________________________ Relationship to the patient ______________