Microsoft word - revised - new patient 2112005.doc
DATE: ________________ Please read these sheets carefully and answer ALL QUESTIONS to the best of your ability. They will assist us in better treating your pain. Thank you for your time and cooperation. NAME:
WHERE IS MOST OF YOUR PAIN TODAY / WHY ARE YOU COMING TO OUR OFFICE, TODAY? (We realize that many of our patients may have multiple sites of pain, or are being referred for one particular type of pain. Therefore, in order to better serve you, and to try and provide you with the best results possible, we can only concentrate on one area at a time before moving to other areas of your body). Please indicate on the diagram below using the symbols to describe the type of pain to that area. Mark the area to where the pain radiates, with using arrows. More than one type of symbol may be necessary—we understand that this may be the case. ACHING NUMBNESS PINS & NEEDLES STABBING DURATION
How long have you had this pain? What was the date of your injury?
What do you believe is the cause of your pain?
Is it constant or does the pain come-and-go
AGRAVATING/ALLEVIATING FACTORS
Please (√) indicate if the following increases or decreases your pain.
INCREASES DECREASES DAILY FUNCTIONING Circle the numbers below that best describe how pain has interfered with your daily functioning. (0=Does not interfere, 10=Interferes greatly) PAIN SCALE Use the following rating scales to indicate how severe your pain is. Circle the appropriate number with 1 being least and 10 being the worst. There is no pain greater than 10. Remember, 10 is the most severe pain possible. (For example, being on fire, while completely awake).
Your pain at its WORST:
Your pain at its LEAST severe:
Your pain on AVERAGE:
Your pain at the PRESENT TIME:
What level of pain do you think you could
PRIOR TREATMENTS Please check any of the following treatments you have had for this pain problem. Include any dates and results. (√) Check all that apply.
ALLERGIES Do you have any allergies to any medications? If so, please list which ones and the exact type of reaction you have. Do you have any allergies to any foods, including shellfish or strawberries? Are you allergic to Latex, iodine, or IVP dye? SURGERY Please list all surgeries you have had and the year. SURGERY
Please list any MEDICAL CONDITIONS you currently have and any illnesses or conditions for which you have been hospitalized. (i.e. osteoarthritis, hypertension, colitis, bipolar disorder, heart attack, seizure, asthma, etc.) Please answer ALL of the following questions. If the item does not apply to you, then mark it NO. We try to take the entire person into consideration, when treating pain—this includes treating the psychological aspect of pain. In order for us to adequately address this area and the needs of these patients, it is necessary for us to have a basic, beginning amount of information on everyone. Please answer truthfully and completely. Omissions and untruthful responses don’t allow us to offer you all benefits one might need for proper healing.
ALCOHOL USE How much beer/alcoholic beverages do you drink? Daily? ___________ Weekly? ___________ Monthly? ___________ I drink:
very infrequently (less than monthly) do not drink
ALTERNATIVE MEDICINE What treatments have you sought to help with pain:
Are the treatments still ongoing? YES NO AUTOMOBILE TYPE Do you drive? YES NO What type of automobile do you drive? AUTOMATIC OR MANUAL If NO, what is the reason for not driving? _____________________________________ CAFFEINE USE How many caffeinated beverages do you drink per day?
EDUCATION LEVEL What level of education do you have? EMPLOYMENT Are you currently employed? YES NO Occupation / Reason for Non-employment______________________________________ ILLEGAL DRUG USE Do you use or have you ever used illegal drugs:
If yes, which drugs do you currently use? ___________________________________
Are you currently in/have you ever attended a substance abuse program? YES NO
LITIGATION Is your pain the result of an accident or injury?
Is there a history of litigation in the past?
Who is your attorney? _________________________________________ MARITAL STATUS
CHILDREN How many children do you have? _________ MENTAL HEALTH HISTORY Have you sought substance abuse treatment in the past?
Have you ever attempted suicide in the past?
Have you been hospitalized for any other psychiatric illness? YES NO If you answered YES to any of these questions, please explain below:
PRESCRIPTION DRUG ABUSE Have you ever been found abusing prescription medications, such as amphetamines, benzodiazepines, barbiturates, codeine, Demerol, or morphine? YES NO SLEEP HABITS Do you sleep on a:
Do you have difficulty falling asleep? YES NO Do you have difficulty staying asleep? YES NO Do you require medication to fall asleep? YES NO If yes, what:_________________ Do wake in the morning feeling rested or still feeling tired? (Check one) Does the pain interrupt your sleep? YES NO If yes, how many time(s) does it awaken you? 1 2 3 TOBACCO USE Do you smoke? YES NO If yes, how many packs a day do you smoke? PLEASE CHECK THE BOX NEXT TO THE CONDITIONS, WHICH YOU HAVE EVER EXPERIENCED. Indicate which of the following medications you have taken in the past for you pain. If a particular medication is not found in the table, write it on the lines provided at the end of this sheet. Narcotics / Opioids Steroid Therapy Pain Relief Adjuncts / Sleep Aids / Anti-depressants Anti-anxiety Medications Sleep Aids Muscle Relaxants / Antispasmodics Pain Relief Adjunct / Anti- convulsant Medications Topical Agents Migraine Medications Natural Medicines Non-steroidal/Anti- Inflammatory Agents
Recomendações sobre drogas da 8ª lista de medicamentos da OMS Introdução Como usar a lista Como as drogas são classificadas em relação à amamentação Considerações adicionais e referências VEJA UM RESUMO dos medicamentos Lista de Drogas Anestésicos Analgésicos, Antipiréticos, Anti-inflamatórios não esteróides, e drogas para tratar de gota Antialérgicos e d