Microsoft word - painques revision.doc

Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 Name: _____________________________________ Date: ____________ Birthdate: ________ Who referred you? ______________________________________________ Phone: __________ Who is your treating physician now? ________________________________ Phone: __________ Describe the pain you have right now (e.g. aching, burning, sharp, etc:) Where is it? What is it like? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ When did the pain begin? __________________________________________________________ If it began with an injury, please describe: _____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Employer when injured: ___________________________________________________________ Position: _______________________________________________________________________ How long employed? ______________ Last day worked: ____________ Still employed? Y N Have you had pain or injury in this part of your body before? Y N (If yes, describe:) ___________ ______________________________________________________________________________ Ever had any other injuries before? Y N (If yes, describe & give dates:) _____________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Total number of surgeries for your pain: ___________ How many times have you been to the Emergency Room in the past 6 months because of pain? __ How many times have you been Hospitalized in the past 12 months because of pain?___________ Rate your usual pain on a scale of 0 to 10 by putting an "x" on the line: ( ) Several times a month ( ) Once a month Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE DESCRIBED SENSATIONS: Use the following symbols. Marks areas of radiation. Include all affected areas. Show main pain areas, use arrows to show spread. PLEASE USE ANY OTHER MARKINGS FOR OTHER TYPES OF PAIN. How often does your pain interfere: work Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 What makes your pain worse?
____ Pain is continuous & activities don't affect _____ Lying on stomach ____ Cough or sneeze _____ Certain positions or movements: ____ Straining or bowel movement ___________________________________ What eases or reduces your pain?
____ Clenching your teeth or making a fist _____ Manipulation (massage, chiropractic,etc) PLEASE CHECK THE TYPE OF TREATMENTS YOU HAVE HAD AND THE RESULTS: Treatment
Who Provided Treatment?
Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 Treatment
Who Provided Treatment?
What do you believe is the cause of your pain? _________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What do you do to manage your pain?________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please describe any episodes of pain which were extremely frightening or in which you lost control: ______________________________________________________________________________ H:\Data\Our Documents\Jim\painques.doc/jm Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 Have there been times when your pain was mild or gone? When? Please describe: ___________ ______________________________________________________________________________ Is anyone in your family or friends able to help you with your pain? Who? ____________________ Describe how: ___________________________________________________________________ How likely is it that your pain can be removed or cured? (Circle one): Do you have particular fears or concerns about the future? (e.g. becoming paralyzed, crippled, needing further surgery, losing emotional control, being unable to support family, etc.) Please list: _ ______________________________________________________________________________ ______________________________________________________________________________ Any other treatments you would like to try? ____________________________________________ ______________________________________________________________________________ ____ Cigarettes, Pipe, Nicotine Chew (Number per day:_______________________) ____ Coffee, Tea, Cola or soda with Caffeine (Total number of cups per day:_______________) ____ Weight control medication . (Type and amount per day:____________________________) ____ Speed, Meth, Cocaine, Uppers, Cross-tops (Type & amount/day:______________________) ____ Downers, Barbs, Ludes, Tranqs (Type & amount/day:_______________________________) Type and duration: _______________________________________________ PRIOR to your injury or pain, did you exercise? Type and duration: _______________________________________________ H:\Data\Our Documents\Jim\painques.doc/jm Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 PLEASE CHECK ANY MEDICATIONS YOU TAKE OR HAVE USED PREVIOUSLY FOR PAIN, ETC: Put a "+" by those that help, "0" by those that don't help, "--" by those that make it worse.
Use
Medication
Medication
Now Before
Narcotics:
Sleeping Aid:
Anti-inflammatories:
Antidepressants:
Celexa, Lexapro (Citalopram, Escitalopram) H:\Data\Our Documents\Jim\painques.doc/jm Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 Medication
Medication
Now Before
Anti-inflammatories:
Antidepressants:
Tranquilizers:
Muscle Relaxers:
H:\Data\Our Documents\Jim\painques.doc/jm Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 Medication
Medication
Now Before
Tranquilizers:
Anti-Convulsants:
Migraine Medications:
Over the counter:
Other medications for pain:
H:\Data\Our Documents\Jim\painques.doc/jm Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 Please List ALL Drugs You Are Currently Taking:
1._____________________________________________________________________________ 2._____________________________________________________________________________ 3._____________________________________________________________________________ 4._____________________________________________________________________________ 5._____________________________________________________________________________ 6._____________________________________________________________________________ 7._____________________________________________________________________________ 8._____________________________________________________________________________ 9._____________________________________________________________________________ 10.____________________________________________________________________________ ALLERGIES: ___________________________________________________________________
MEDICAL HISTORY: (Please list approximate dates and where)
MEDICAL CONDITIONS OR SERIOUS ILLNESS: ______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SURGERIES: ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ INJURIES:______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ OTHER HOSPITALIZATIONS: ______________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ WHEN WAS YOUR LAST COMPLETE MEDICAL EXAM? ________________________________ CHEST XRAY? ____________________________________________________________ PAP SMEAR (Women only)?__________________________________________________ MAMMOGRAM? ___________________________________________________________ PROSTATE EXAM (Men only)?________________________________________________ HIV test/Hepatitis screen? ____________________________________________________ H:\Data\Our Documents\Jim\painques.doc/jm Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 FAMILY HISTORY:
CHECK FOLLOWING IF ANY FAMILY MEMBERS ARE AFFECTED. PLEASE NOTE WHO IS Mother's age ______________ Alive?__________ Father's age___________ Alive?_________ Spouse's/Partner's name, age and health _____________________________________________ SOCIAL HISTORY:
Single? _______ Married?_______ Partnered?_______ Divorced?_______ Widowed?______ Number of children ______________ Their ages and sex ________________________________ ________________________________ Number of children still living with you________________ Current occupation:_______________________________________________________________ Full Time______ Part Time______ Hours/Wk______ Time Loss______ Compensation:$ ____ Grade completed in school_______ Degree & School ___________________________________ Previous work experience (briefly): ___________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Religious preference ______________________________________________________________ Religious background _____________________________________________________________ Service organizations _____________________________________________________________ H:\Data\Our Documents\Jim\painques.doc/jm Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 RECENT HEALTH STATUS:
CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU IN THE PAST 3 TO 6 MONTHS. Explanations or anything else important to your health ___________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Is there anything else you would like to tell the doctor today? ______________________________ ______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ H:\Data\Our Documents\Jim\painques.doc/jm Pain Management Partners LLC- James R. Morris, MD 2401 River Rd. Suite 101 Eugene, OR 97404 (541) 344-8469 Fax 687-8631 Disability Questionnaire
Are you applying for disability benefits or are you currently disabled? Yes ___ No___
If not, please skip to the signature line. Please indicate the amount of time you can do these activities by using the spaces provided. Thank you for taking time to complete this form. Please return to the receptionist, or mail in to: Pain Management Partners, LLC Dr. J. Morris, 2401 River Rd. Suite 101, Eugene, OR 97404. .Signature__________________________________________ H:\Data\Our Documents\Jim\painques.doc/jm

Source: http://www.oregonpainmanagement.com/shop/images/New_Patient_Medical_History.pdf