Unifour Pain Treatment Center Patient Data Form

UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
Please complete this form prior to your appointment. Please be as accurate as possible. The information is
confidential and will be available to your health care team and their staff only.
PLEASE BRING THIS FORM WITH YOU ON YOUR NEXT VISIT.
PATIENT INFORMATION:
Full Name:
Date of Birth:
Address:
Home Phone:
______
Work Phone:
______
May we contact you at work? Yes ( ) No ( )
Email (optional):
Cell:
Social Security Number: _______________________
___
Sex: Male ( ) Female ( )
Age:
Contact person in case of emergency:
Name:
Home Phone:
Cell / Work Phone:
Spouse’s Social Security Number: _________________________________________________
Spouse’s Employer:
Spouse’s Date of Birth:
Approximate distance from your house to our office: _________ miles
How long is your expected travel time to our office? _________
Name, address, and phone of your pharmacy:
INSURANCE INFORMATION:
Please Bring All Insurance Cards With You
Insurance Company:
Certificate No.: ________________________________
Group No.: ____________________
___
Insured Name:
Relationship to you: ( ) self ( ) spouse ( ) other
Additional Insurance: __________________________________________________
Certificate No.:
________ __
Group No.:
Insured Name:
Relationship to you: ( ) self ( ) spouse ( ) other
RN Initials:
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 1 OF 11
PRIOR TREATMENT:
Please list the full name, address, phone number, and practice name of your:
Family Physician or Internist
______________________________________
______________________________________
______________________________________
Referring Doctor (if different)
________________________________________
________________________________________
________________________________________
Listed below are different medical specialties. Indicate if you have seen any of these specialists for your pain
condition. List doctor’s full name, location, and name of practice. (Please fill in names that apply.)
Specialty
Doctor’s Name
Specialty
Doctor’s Name
Allergist
Anesthesiologist
Cardiologist (heart)
Chiropractor
Dermatologist (skin)
Dentist/Oral Surgeon
Ear, Nose, & Throat
Endocrinologist
General/Family Practice
Internal Medicine (internist)
Neurologist (nervous system)
Neurosurgeon
Obstetrician/Gynecologist
Oncologist/Hematologist
(cancer/blood)
Ophthalmologist (eyes)
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Orthopedic Surgeon (bones)
Pain Specialist
Pediatrician (children)
Plastic Surgeon
Psychiatrist/Psychologist
Physiatrist (rehab)
Radiation Oncologist
Rheumatologist (arthritis)
Physical Therapy Therapist:
Facility:
Acupuncturist
Herbalist
Other
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
# of emergency room visits
for pain within the last year?
______________
______________
List doctor’s full name, location, and name of practice. ______________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you ever been to a pain clinic before? If so, please give name, location, and type of therapy performed:
HISTORY OF PRESENT ILLNESS:
When did your pain begin?
What part(s) of your body hurts?
If multiple areas of pain, which is the worst area?
RN Initials: ________
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 2 OF 11
Please describe what happened or exactly how this pain began (if related to an accident, give date & details):
____________________________________________________________________________________________
____________________________________________________________________________________________
Do you know or have been told what is causing your pain?_____________________________________________
___________________________________________________________________________________________
On the following scale, rate your pain right now: (circle one)
PAIN SCALE: 0
1
No Pain
2
3
4
5
6
7
8
9
10
Extreme Pain
5
6
7
8
9
10
Extreme Pain
5
6
7
8
9
10
Extreme Pain
On the following scale, rate your average daily pain: (circle one)
PAIN SCALE: 0
1
2
3
4
No Pain
On the following scale, rate you pain at its worst: (circle one)
PAIN SCALE: 0
1
No Pain
2
3
Describe your pain sensations: (check all that apply)
Dull ache
___
Twisting
___
Burning
___
Throbbing
___
Continuous
___
Grinding
___
Electric shock ___
Pressure
___
Sharp/stabbing ___
Tearing
___
What makes your pain BETTER: (check all that apply)
Sitting
___
Applying heat ___
Standing
___
Applying cold ___
Moving around ___
Massage
___
Lying down
___
Exercise
___
_______________________
What makes your pain WORSE: (check all that apply)
Sitting
___
Applying heat
___
Standing
___
Lifting
___
Moving around ___
Massage
___
Lying down
___
Exercise, bending ___
Driving
___
Damp weather
___
4
Superficial (on surface) ___
Deep
___
Stinging
___
Other: _______________________
_______________________
Medications
___
Nerve blocks
___
Stretching
___
Physical Therapy
___
Other: _______________________
Medications
___
Nerve blocks
___
Physical therapy
___
Other: _______________________
_______________________
Circle the treatments you have tried for pain: Heat Cold
Acupunture Chiropractor Injections TENS Surgery
Medications Physical Therapy Biofeedback
Spinal Cord Stimulator Intrathecal Pump
Other: ______________________________________________________________________________________
What treatment (including medications) has helped your pain the most? ________________________________
____________________________________________________________________________
_
RN Initials: ________
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 3 OF 11
PAST MEDICAL HISTORY / REVIEW OF SYSTEMS:
Please indicate if you have or have had any of the following medical conditions: (please answer all)
Cardiovascular:
Heart attack
Stroke/TIA
High blood pressure
Date of last EKG:
Where performed:
Chest pain/angina
Irregular heart beat
YES
NO
____ When? ____
____ When? ____
____
____
__________ ____
_______________
_______________
____
____
____
____
Gastrointestinal:
Ulcers/gastritis
____
Frequent constipation
____
Frequent diarrhea
____
Freq. heartburn/indigestion____
Nausea
____
Incontinence of stool
____
Hematologic:
Immune diseases
____
Hemophilia
____
Taking blood thinner
____ Name:
Frequent nose bleeds
____
Bleeding problems
____ Specify:
Genitourinary:
Kidney function problems ____
Kidney stones
____
Problems urinating
____
____
____
____
____
Respiratory:
YES
NO
Asthma
____
____
Smoking now
____
____
# packs per day ____
If quit, when? _________ # years smoked ____
Lung disease
____ Specify: ___________
Sleep apnea
____
____
Snoring
____
____ CPAP? ____
Chronic cough
____
____
Shortness of breath ____
____
Neurological:
Seizures/epilepsy ____
____
Numbness
____ Where? ____
Weakness
____ Where? ____
Headaches
____ How often? ____
Dizziness
____ How often? ____
Restless legs
____
____
Endocrine:
Thyroid problems ____
____
Diabetes
____
____
on insulin?
____
____
Liver problems
____ Specify: ____
Hepatitis
____ Type? ____
Emotional/Psychiatric:
Depression
____
____
Anxiety/panic
____
____
Violent behavior
____
____
Irritability
____
____
Suicidal thoughts ____
____
Eyes, Ears, Nose, Throat:
Visual problems
____
____
Hearing loss
____
____
Bleeding gums
____
____
Problems swallowing____
____
____
____
____
____
List major diseases / medical illnesses:
__________________________________
__________________________________
__________________________________
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Specify type of problem: _______________________
Sexual function problems ____
Musculoskeletal:
Fibromyalgia
____
Arthritis
____
Chronic Fatigue Syndrome ____
Skin color/temp changes ____
Constitutional:
Frequent fevers
____
Recent weight loss
____ lbs.
Recent weight gain
____ lbs.
Frequent night sweats
____
____
Possibility you are pregnant? ( ) yes ( ) no
Your Height: _____________
RN Initials: ________
Weight: _____________
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 4 OF 11
On average, how many hours per night do you sleep? ________ hrs.
If you awaken frequently, what is the cause? ________________________________________________________
Have you ever been diagnosed with cancer? ( ) yes ( ) no
If yes, type of cancer: ______________________________________________________
Date of last cancer follow-up: _______________ Doctor treating you for cancer: _________________________
How much alcohol (beer, wine, liquor) do you consume per week? __________________ /week
Do you use any street drugs? ( ) yes ( ) no
If yes, specify:_______________________________________
Have you ever used prescription drugs for non-medical reasons? ( ) yes ( ) no
Have you ever had a problem with drugs (prescription or non-prescription) or alcohol in the past? ( ) yes ( ) no
If yes, specify: ______________________________________________________________________________
MEDICATIONS:
Please list all your current medications below (include over-the-counter drugs):
Name of Drug & Strength
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
Number Taken per Day
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
Prescribing Doctor
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
Have you been on any of the following medications for your current pain problem?
( ) narcotics ( ) tranquilizers ( ) muscle relaxants ( ) anti-inflammatories ( ) steroids
List everything (including medications & tape) that you are ALLERGIC or have bad reactions to:
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
Have you ever had a reaction to intravenous contrast (dye) or iodine? ( ) yes ( ) no
Are you allergic to any shellfish? ( ) yes ( ) no
RN Initials: ________
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 5 OF 11
SURGICAL HISTORY:
Have you ever had surgery to relieve your current pain condition? ( ) yes ( ) no
If yes, indicate surgeon name, location where procedure performed (i.e. hospital name), date, and type of surgery:
____________________________________________________________________________________________
If no, have you been told you may need surgery for your current pain problem? ( ) yes ( ) no
List all major surgeries which you have had in the past:
Name of Surgery
____________________
____________________
____________________
Where & Date Performed
_____________________________
_____________________________
_____________________________
Name of Surgeon
____________________
____________________
____________________
Have you ever had a problem with anesthesia? ( ) yes ( ) no
If yes, please specify:
SOCIAL HISTORY:
Current Marital Status: Single ( )
Married ( )
Widowed ( )
Divorced ( )
Number of children ______ Ages of children _____________ Children living with you _______
Highest level of education completed: ( ) grade school ( ) high school ( ) college/technical ( ) graduate school
Is there pending litigation related to your pain or a previous accident? ( ) yes ( ) no
If yes, your attorney’s name, address, and phone:
GOALS:
Please indicate the types of things you would like to be doing, but cannot because of pain:
Of the things listed above, which one is the most important to you?
_____________________________________________________________________________
Do you believe that 100% pain relief is possible in your condition? ( ) yes ( ) no ( ) don’t know
RN Initials: ________
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 6 OF 11
EMPLOYMENT INFORMATION:
If you are currently EMPLOYED, please answer the following: (If not employed, skip to next section.)
Employer Name and Address:
_____________________________________________________
I am employed: ( ) full-time ( ) part-time Average hours worked per week __________
How long have you been with your current employer? ____________________
Are you currently on Workmen’s Compensation? ( ) yes ( ) no
Do you like your job? ( ) All the time ( ) Most of the time ( ) Some of the time ( ) Rarely or not at all
Are your duties at work restricted by your employer currently (e.g. light duty)? ( ) yes ( ) no
Briefly describe what you do at work; include time standing, sitting, lifting and weight of items lifted, if applicable:
______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
If you are currently NOT EMPLOYED, please answer the following:
Have you ever been employed? ( ) yes ( ) no (If no, skip to next section.)
Last Employer Name and Address:
_____________________________________________________
Please state whether ( ) unemployed ( ) disabled ( ) retired How long? _______________
If disabled, state reason(s) and physician who authorized disability:
____________________________________________________________________________
_____________________________________________________________________________
Did you like your job? ( ) All the time ( ) Most of the time ( ) Some of the time ( ) Rarely or not at all
Briefly describe what you did at work, include time standing, sitting, lifting and weight of items lifted, if applicable:
______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
RN Initials: ________
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 7 OF 11
Have you stopped working because of your current pain condition? ( ) yes ( ) no
If yes, have you attempted to return to work? ( ) yes ( ) no
If yes, ____ full-time or ____ part-time.
Do you want to return to work? ( ) yes ( ) no
SEXUAL HISTORY:
Are you sexually active? ( ) yes ( ) no
Do you protect yourself from sexually transmitted diseases and HIV (e.g. use of condoms)? ( ) yes ( ) no
Have you or do you currently have a sexually transmitted disease (e.g. herpes, chlamydia, gonorrhea, etc.) ( ) yes ( ) no
If so, please specify type and year: _______________________________________________________________
Do you have a history of sexual abuse? ( ) yes ( ) no
When? ______________________________________
MILITARY HISTORY:
Have you ever served in the armed forces? ( ) yes ( ) no
If so, list branch, years of service and location: ______________________________________________________
Do you have any pain and/or psychiatric conditions as a result of military service? ( ) yes ( ) no
If so, please specify what those are: ______________________________________________________________
FAMILY HISTORY:
Does any member of your immediate family have a problem with drugs or alcohol? ( ) yes ( ) no
If yes, please specify: _____________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Do any members of your immediate family have a chronic pain condition? ( ) yes ( ) no
If yes, please specify: _____________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
____________
____________
Does your immediate family have a history of hereditary diseases or other major illness? ( ) yes ( ) no
If yes, please list:_________________________________________________
____________
_____________________________________________________________________________
_____________________________________________________________________________
RN Initials: ________
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 8 OF 11
DIAGNOSTIC STUDIES:
Indicate which of the following studies/tests you have had to work-up your current pain problem:
Type of Study
Where Performed
Approximate Date
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
(check all that apply)
MRI
CT scan
Myelogram
EMG/nerve study
Plain x-rays
Bone scan
Ultrasound
Sleep study
Blood flow study
Stress test/treadmill
Cardiac cath
Nerve block/steroid inj
Other:
____
____
____
____
____
____
____
____
____
____
____
____
____
PLEASE FILL OUT PAIN DIAGRAM AND MEDICATION HISTORY FORM ATTACHED TO THIS PACKET
I give permission to discuss my medications, medical condition, and/or billing issues with the following person(s)
listed (e.g. spouse, significant other, family, friends):
____
_______________________________________________________________________________________
By signing below, I acknowledge that the above information is true and accurate to the best of my knowledge.
______________________________________
Your Signature
____________________
Date
____________________
Time
______________________________________ ____________________
RN Signature
Date
____________________
Time
______________________________________
Physician Signature
____________________
Time
____________________
Date
Thank you very much for taking time to provide us with this needed information.
RN Initials: ________
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 9 OF 11
Mark on the drawing the exact spot where your pain is with a solid black dot. If the pain starts at that spot and
radiates elsewhere (travels to another part of your body), draw a line from the spot where it starts to where it ends.
If it is a whole area that hurts, shade in that area with a pencil.
Next to the places on drawing where you showed the pain, put an “E” if the pain is External (on the outside
surface). If the pain is Internal (inside the body) mark it with and “I”. If the pain is both Internal and External, mark
“EI”.
Mark also “C” for Constant, “O” for Often, or “S” for Seldom depending on how much of the time you experience the
pain.
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 10 OF 11
MEDICATIONS:
Please underline each medication you have used in the past. Please circle each medication you are now using.
ANALGESICS
Actiq
Anacin
Aspirin
Avinza
BC Powder
Bufferin
Buprenex/Buprenorphine
Butrans Patch
Butalbital
Codeine
Darvocet
Darvon
Demerol
Dilaudid/Hydromorphone
Duragesic Patch
Embeda
Equagesic
Esgic
Exalgo
Excedrin
Fioricet
Fiorinal
Goody’s Powder
Hydrocodone
Hysingla
Kadian
Lidoderm Patch
Lorect/Lortab
Methadone
Morphine
MS Contin
Norco
Nubain
Opana IR
Opana ER
Oxycontin
Oxy IR
Percocet
Percodan
Propoxyphene
Roxicet/Roxicodone
Ryzolt
Sedapap
Stadol Injection
Stadol Nasal Spray
Suboxone
Talwin
Tylenol/Acetaminophen
Tylenol #3 or #4
Tylox
Ultram/Ultracet
Vicodin
Vicoprofen
Zydone
ANTI-MIGRAINE
MEDICATIONS
Amerge
Axert
Bellergal
DHE-45 Injection
DHE Capsule
Duradrin
Ergomar
Ergotrate
Frova
Imitrex Injection
Imitrex Nasal Spray
Imitrex Tablet
Lidocaine
Maxalt
Midrin
Relpax
Sansert
Zomig
ANTI-INFLAMMATORIES
Advil/Ibuprofen
Aleve/Naproxen
Anaprox
Anasaid
Arthrotec
Aspirin
Bextra
Cataflam
Celebrex
Daypro
Diclofenac
Dolobid
Feldene
Indocin
Ketoprofen
Lodine
Meclomen
Mobic
Motrin
Nalfon
Naprosyn
Nuprin
Pensaid
Relafen
Toradol
Trilisate
Voltaren
Voltaren Gel
MUSCLE RELAXANTS
Baclofen
Flexeril
Lioresal
Norgesic
Parafon Forte
Robaxin
Skelaxin
Soma
Zanaflex
ANTI-CONVULSANTS
Depakote
Dilantin
Gabitril
Gralise
Keppra
Klonpin
Lamictal
Lyrica
Neurontin/Gabapentin
Phenobarbital
Tegretol
Topamax
Trileptal
Zonegran
STEROIDS
Decadron
Dexamethasone
Hydrocortisone
Medrol
Prednisone
SLEEPING PILLS
/TRANQUILIZERS
Ambien
Ativan
Benadryl
BuSpar
Dalmane
Halcion
Librax
Librium
Lorazepam
Lunesta
Melatonex
Melatonin
Restoril
Rozerem
Seconal
Seroquel
Sonata
Thorazine
Tranxene
Trilafon
Tylenol PM
Valium
Xanax
Zyprexa
ANTI-DEPRESSANTS
Abilify
Anafranil
Amitriptyline
Celexa
Cymbalta
Desipramine
Desyrel
Doxepin
Effexor
Elavil
Geodon
Imipramine
Lexapro
Lithium
Luvox
Nardil
Nortiptyline
Pamelor
Paxil
Pristiq
Prozac
Remeron
Savella
Serzone
Sinequan
Tofranil
Trazodone
Vivactil
Wellbutrin
Zoloft
HERBAL (please list)
_________________
_________________
_________________
_________________
UNIFOUR PAIN TREATMENT PHYSICIANS
PATIENT DATA FORM
PAGE 11 OF 11