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Patient Assessment Form
(Please fill out this form and bring it with you to your appointment.) Name_____________________________________ Age______ Sex: M ____ F ____ Date _____________ Date of Birth _______________ Weight _________ lbs

Height: _____ft. _____ in.

Primary Physician _________________________________ Referring Physician (If Different)______________________ __________________________________ ______________________

CURRENT PROBLEM
Please draw where your primary pain is located using the diagrams below:

When did the pain begin? _______________________________________________________________________ Did it begin gradually or suddenly? _______________If suddenly, is it the result of an injury? ____Yes ____No If result of an injury, describe the injury_____________________________________________________________ If not a result of injury, what do you think caused your pain? ___________________________________________ _______________________________________________________________________________________________ Since your pain started is it (circle one) Worse Unchanged Intermittent Better NA

Please describe your pain in as much detail as possible _______________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Do you have any other symptoms such as numbness, weakness, or pins and needles sensation? Please describe. ____________________________________________________________________________________________ ____________________________________________________________________________________________

CURRENT PROBLEM CONTINUED…
Patient Assessment Form Center for Pain Medicine Shawnee Mission, Kansas 66204 Form # 62358 Rev: 5-22-07 Page 1 of 8

Patient Assessment Form
What makes your pain worse? Standing_______ Sitting_______ Walking_______ Lying Down_________________ Other____________________________________________________________________________________________ What have you found that makes your pain better? _____________________________________________________ Does your pain affect your sleeping? Yes____ No_____ If so, how?__________________________________ Difficulty controlling your bladder Yes___ No___

Do you have difficulty controlling your bowels? Yes ___ No___

Please mark your average (A) and maximum (M) pain level on the line below.
0 1 2 3 4 5 6 7 8 9 10 No Pain____I_____I_____I____I____I____I____I____I____I____I____ Worst Pain Imaginable

Was the injury work-related? Yes____ No____ Does the pain interfere with your ability to work?

Are you involved in a lawsuit? Yes____ No_____

Yes ____No_____

If so, how? ________________________________________________________________________________ Does the pain interfere with your daily activities? Yes____ No_____ If so, how? ________________________________________________________________________________ Do you need assistance with walking? Yes____ No____ Assistive Device? ________________________________ If yes, is this assistive device preventing falls? Have you had any recent falls? ___Yes ___No ___________________________________________________________________________________________

SUBJECTIVE ASSESSMENT OF THE HOME ACTIVITY LEVEL
Please indicate which activities of daily living cause the greatest difficulty
PERSONAL Dressing upper body Dressing lower body Bathing Hair care Sleeping Yard work/gardening Child Care _______ HOUSEHOLD CHORES Meal preparation Shopping Home Repairs House cleaning Shoveling snow Twisting Up and Down Stairs _______ _______ GENERAL MOBILITY Sitting Bending Getting in/out of bed Standing Walking Lifting Getting in/out of car

Patient Assessment Form Center for Pain Medicine Shawnee Mission, Kansas 66204 Form # 62358 Rev: 5-22-07 Page 2 of 8

Patient Assessment Form
HISTORY OF TREATMENTS Please indicate whether or not you have had any of these tests for your present problem:
YES REGULAR X-RAYS CT SCAN MYLEOGRAM MRI BONE SCAN BLOOD TESTS EMG (nerve test) DISCOGRAM NO WHEN WHERE

Please indicate the following treatments you have tried in the past.
TREATMENTS Exercise Physical Therapy Occupational Therapy Chiropractic Counseling Biofeedback Injections/Nerve Block TENS Unit Medications DATE BETTER yes no OUTCOME NA

HISTORY OF PAST PROVIDERS
Please list the names of all physicians, chiropractors, psychiatrist, psychologist, osteopaths, or other pain facilities whom you have seen for your present problem. List them in the order in which you saw them from first to last. NAME OF PHYSICIAN SPECIALTY
DATE FIRST SEEN DATE LAST SEEN

Patient Assessment Form Center for Pain Medicine Shawnee Mission, Kansas 66204 Form # 62358 Rev: 5-22-07 Page 3 of 8

Patient Assessment Form
PAST MEDICAL HISTORY
Do you have or have you had any of the following conditions? (Please Check All That Apply) ENDOCRINE __Diabetes __Hypo/Hyperthyroid CARDIAC __Heart Attack __Congestive Heart failure __Coronary Artery Disease __Valvular heart Disease __High Blood Pressure RESPIRATORY __Asthma __Bronchitis __Emphysema/COPD HEMATOLOGY __Bleeding disorder __Anemia GENITOURINARY __Incontinence __Bladder control problems __Kidney disease __Kidney infections RHEUMATOLOGY __Arthritis, Type___________ __Fibromyalgia GASTROINTESTINAL __Ulcers __Gallstones __Liver Disease __Hepatitis __Pancreatitis __GERD/reflux disease OTHER __Cancer, Type_________ _________________ _________________ _________________ _________________

PSYCHIATRIC __ Bipolar disease __ Depression __History of Drug/Alcohol problems __Other mental illness_____________ __ Anxiety Please provide any additional about the above conditions below, or list other conditions not covered on the above list: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

NEUROLOGICAL __Stroke/TIA __Migraines

PAST SURGICAL HISTORY
Please list any surgeries you have had including procedure and date:

Surgery

Year

Facility/Physician

Patient Assessment Form Center for Pain Medicine Shawnee Mission, Kansas 66204 Form # 62358 Rev: 5-22-07 Page 4 of 8

Patient Assessment Form
CURRENT MEDICATIONS

ARE YOU TAKING ANY BLOOD-THINNING MEDICATIONS? (e.g. ASPIRIN, COUMADIN, HEPARIN, TICLID, PLAVIX (CLOPEDIGREL) PLETAL, LOVENOX, ARISTA, JANTOVEN, WARFARIN, OTHER ___________________ YES________ NO__________

Please list any medications you are currently taking. Include vitamins, over-the-counter medications, herbal preparations, laxatives, or inhalers. Medication & Dose How often Medication & Dose How often

1) 2) 3) 4) 5) 6) 7) 8) 9)

10) 11) 12) 13) 14) 15) 16) 17) 18)

DRUG ALLERGIES DO YOU HAVE ANY ALLERGIES? reaction: YES NO If yes, please list the medication and the

This includes: medications, food, latex, iodine, environmental agents or irritants

Item/Drug

Reaction

Item/Drug

Reaction

Patient Assessment Form Center for Pain Medicine Shawnee Mission, Kansas 66204 Form # 62358 Rev: 5-22-07 Page 5 of 8

Patient Assessment Form
REVIEW OF SYSTEMS Do you have any of the following symptoms? Please circle all that apply.
• • • • • • • • • • • • • • GENERAL: Weight loss, rashes, itching, color changes, headaches, dizziness, fever or chills, night sweats EYES: Blurred vision, light sensitivity, deficits in your vision, changes in your vision. EAR,NOSE,THROAT: Sinus problems, trouble swallowing, ringing in your ears, dental problems. CARDIAC: Chest pain, palpitations, poor circulations, swelling in extremities, poor exercise tolerance REPIRATORY: Shortness of breath, difficulty breathing, wheezing, coughing, sputum production. URINARY: Painful urination, difficulty urinating, bladder control problems, frequent urinary infections. GASTROINTESTINAL: Heartburn, nausea, vomiting, diarrhea, bloody stools, constipation. MUSCULOSKELETAL: Achy swollen joints, stiff joints, muscle spasms, sore/ tender muscles. SKIN: Rashes, skin irritations, skin ulcers. NEUROLOGICAL: Poor memory, headaches, poor balance, loss of consciousness, fainting, muscle weakness, numbness, or changes in sensation. PSYCHOLOGICAL: Anxiety, depression, increased emotional stress, hallucinations, paranoia, suicidal ideations (thoughts of harming yourself difficultly with concentration. ENDOCRINE: Always thirsty, always hot, always cold, hair and nail changes. HEMATOLOGY: Easy bruising, cuts take a long time to stop bleeding, painful lymph nodes, frequent leg swelling, fatigue. ALLERGIC/IMMUNE: are you prone to infections, sensitive to many foods, medicines

FAMILY HISTORY
Please list any significant medical problems for any blood relatives(parents, grandparents, brothers or sisters) also list any medical problems that tends to run in your family.
__________________________________________________________________________________________________ __________________________________________________________________________________________________

__________________________________________________________________________
SOCIAL HISTORY
Marital Status: Single___ Married____ Divorced____ Widowed____ Spouse____ Children____ Other____

Indicate current household members: Self____

What kind of support do you have to help you cope with this problem? (e.g. family, friends, church, etc.) __________________________________________________________________________________________________ Patient Assessment Form Center for Pain Medicine Shawnee Mission, Kansas 66204 Form # 62358 Rev: 5-22-07 Page 6 of 8

Patient Assessment Form
EXERCISE: Type of exercise:____________________________________________________________________ Days/Week:________________________________________________________________________ TOBACCO USE: Do you currently use tobacco products? ____Yes ____NO IF YES, how many packs a day? _________________ How many years?_________________________ IF FORMER SMOKER, when did you quit?_________before you quit, how many packs a day ___ and how many years_____ Do you drink caffeinated beverages? Do you drink alcoholic beverages? YES YES NO If yes, how many cups/cans per day? _______________ NO If yes, how many beverages per week? _________________

Have you ever had, or do you have a substance abuse problem? Yes___ No__

Are you currently employed? ___Yes ___No. If yes please complete the following questions: Your current employer _______________________________________________________________________ Your current occupation ______________________________________________________________________ Your usual duties include: ____________________________________________________________________ Are you involved with Workman’s compensation? ____Yes ____No If so, what is the name and phone number of your case worker? ____________________________________

OTHER Is there any chance you could be pregnant?
Primary Language: English YES Spanish NO

YES

NO

If yes, when is your due date?
YES NO

Other______________ Do you need an interpreter? Do you need glasses to read? YES YES NO NO YES

Are you hard of hearing?

Would you like to have a consult with a dietician to discuss any dietary concerns?

Are there any religious or cultural factors which may impact your care while in the clinic?

NO

If yes, please explain_____________________________________________________________________ Do you, or anyone you know, need information regarding problems of abuse and/or neglect? Yes _____ No _____ What are your realistic goals for treatment of your pain? (check all that apply)

To be pain free ____ Reduced pain _____

Help living with pain ____ Increased activity _______

Other ____________________

___________________________________________________________________________________________________ Thank you for your time in completing this form Patient signature ________________________________________ Patient Assessment Form Center for Pain Medicine Shawnee Mission, Kansas 66204 Form # 62358 Rev: 5-22-07 Page 7 of 8

Patient Assessment Form

Assessment reviewed with Patient by: R.N. Date M.D. Date

Assessment reviewed with Patient by: R.N. Date M.D. Date

Assessment reviewed with Patient by: R.N. Date M.D. Date

Assessment reviewed with Patient by: R.N. Date M.D. Date

Assessment reviewed with Patient by: R.N. Date M.D. Date

Assessment reviewed with Patient by: R.N. Date M.D. Date

Patient Assessment Form Center for Pain Medicine Shawnee Mission, Kansas 66204 Form # 62358 Rev: 5-22-07 Page 8 of 8

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