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Microsoft word - npquestion.docx

PAIN SOLUTIONS
NEW PATIENT QUESTIONNAIRE

Patient Name: __________________

DATE______________________
Primary Doctor: _____________________________ Referring Doctor: _____________________

Please show the location of your pain by drawing on the figures below:

Pain History (PLEASE FILL IN THE BUBBLES)
1. WHERE IS YOUR PAIN LOCATED?
2. WHERE DOES THE PAIN RADIATE?
3. THE PAIN FIRST STARTED:
Was there an accident or injury that caused the pain?
O YES _____________________________________________________________________
4. HOW WOULD YOU DESCRIBE YOUR PAIN? (mark all that apply)
5. RATE YOUR PAIN AT IT’S WORST IN THE LAST 24 HOURS?
6. RATE YOUR PAIN AT IT’S BEST IN THE LAST 24 HOURS?
7. HOW SEVERE IS YOUR PAIN ON AVERAGE?
8. HOW MUCH DOES THE PAIN INTERFERE WITH YOUR ACTIVITIES?
9. HOW MUCH DOES THE PAIN INTERFERE WITH YOUR SLEEP?
10. THE PAIN IS:
11. WHAT MAKES THE PAIN WORSE?
12. WHAT MAKES THE PAIN BETTER?
13. IN ADDITION TO THE PAIN, DO YOU HAVE?
14. IS YOUR PAIN:
15. WHAT TESTS HAVE YOU HAD FOR YOUR PAIN? (Please list date of last exam)
O MRI Scan_____________ O CT Scan____________ 16. WHAT MEDICATIONS HAVE YOU TRIED FOR YOUR PAIN? (Check ALL that apply)
Anti-Inflammatory: O Ibuprofen (Advil, Motrin)
Narcotic:
Antidepressants
O Fluoxetine (Prozac) O Escitalopram (Lexapro) O Venflaxine (Effexor) O Sertraline (Zoloft) O Nortriptyline (Pamelor) O Desipramine (Norpramine) O Citalopram (Celexa) O Paroxetine (Paxil) Anti-Seizure
O Pregabalin (Lyrica) O Zonisamide (Zonegram) O Lamotrigine (Lamictal) O Oxycarbazepine (Trileptal) Muscle Relaxants/
O Tizanidine (Zanaflex) O Metaxolone (Skelaxin) Anti-Anxiety
O Cyclobenzaprine (Flexeril) O Methocarbamol (Robaxin) Sleeping Aids
Other Pain Meds
17. WHAT TREATMENTS HAVE YOU HAD FOR YOUR PAIN?
O Other __________________________________________________ Past Medical History (Please Fill in “yes” or “no” to all questions)
CARDIOVASCULAR
GASTOINTESTINAL
RESPIRATORY
NEUROLOGY

Social History
Drug(s) Used ____________________________________
OTHER SYMPTOMS
(Please indicate other symptoms you may have)
CONSTITUTIONAL
NEUROLOGY
RESPIRATORY
MUSCULOSKELETAL
CARDIOVASCULAR

HEMATOLOGY

CURRENT MEDICATIONS (Include dosage and # tablets per day)

Have you had any surgeries? _____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Are you taking any of the following blood thinners? ___ Coumadin

___ Plavix

Do you have any allergies to medications?

___ Latex
___ Iodine
__Other Medications? ___________________

What are your goals for your pain treatment?
__________________________________________________________________________________
__________________________________________________________________________________
Are there any specific treatments that you would like for your pain?

Medications: __________________________________________________
Physical Therapy: ______________________________________________
Exercise: ______________________________________________________
Psychologist referral: ___________________________________________
Surgery referral ________________________________________________

Injections: ______________________________________________________
Other pain therapies: (Please circle)

Do you have a driver with you today? __ yes __ no

THIS IS THE END OF THE QUESTIONNAIRE. THANK YOU!

Source: http://www.nmpainsolutions.com/resources/npquestion2.pdf

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