Microsoft word - 2012 comp pain assessment

A Renaissance Health Center for Natural Medicine
130 NW Miller Ave., Gresham, OR 97030 PH: 503.665.2344 FAX: 503.66.2337
DATE: ___________________

PT. NAME: __________________________________________ SEX M F DOB _________AGE _____
ADDRESS ______________________________________________________________________________
CITY _______________________ STATE _________ZIP___________ HOME PH______________________
WORK PH ______________________ EMAIL _________________________________________________
PRIMARY DOCTOR __________________________________________ PH _________________________
EMERGENCY CONTACT ______________________________________PH _________________________
Have you been diagnosed with a pain condition/limitation? Please describe here:

Previous Medications:
NSAIDS: aspirin, ibuprofen,advil, motrin, naprosyn Relaxants: flexeril, valium, xanax, ativan, librium Sleep Meds: ambient, restoril, benedryl, halcion Anti-Depressants: elavil, amitryptilline, Prozac, effexor, Zoloft, deseryl, paxil, pamelor, serozone, desipramine, remeron Narcotics: vicodin, darvocet, tylenol3, tylox, codeine, Percocet, percodan, MS Contin, oxycontin, Demerol, morphine, methadone Neuropathic Pain Meds: neurontin, klonopin, tegretol, dilantin, baclofen, utram, prozocin, mexitil, On average it takes ____minutes/hours to fall asleep. It is _getting better _ getting worse _staying the It takes me __ minutes/hours to get back to _accident (date _/_) _ work injury _ other injury _ following operation _ cancer _ no cause What makes your pain better? What treatments have you tried for your pain? Pain “0” = NO PAIN – Pain “10” WORST PAIN

Have you ever been told you have any of the following: (Check all that apply)



CANCER __________________
Circle area(s) that pertain to your current pain

Current Medications you are taking:

Med Dose How Often Last Dose
Previous Surgeries:
Any legal./occupational issues pending in regard to your pain conditions? Yes No
With whom do you live? Self _ Spouse _ Children_ Parents _ Friends _ Partner _
PATIENT SIGNATURE _________________________________________ DATE____________


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