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PLEASE ARRIVE Michigan Interventional Pain Associates

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					PLEASE ARRIVE 15 MINUTES EARLY FOR YOUR APPOINTMENT

MICHIGAN INTERVENTIONAL PAIN ASSOCIATES

     STEVEN WIENER, M.D.  CAIN DIMON, M.D.
             SHARON MINOTT, M.D.

2300 HAGGERTY RD., SUITE 2100
WEST BLOOMFIELD, MI 48323
(248)624-PAIN FAX (248)624-2597


PATIENT NAME:
PATIENT ADDRESS:
PATIENT TELEPHONE:


REFERRING DOCTOR:
PHONE:


PRIMARY DOCTOR:
PHONE:
ADDRESS:


*PLEASE COMPLETE ATTACHED FORMS.

*MEDICAL RECORDS, PROGRESS NOTES, AND
REPORTS FORM MRI, CT, X-RAY, ETC, ARE NEEDED
PRIOR TO YOUR APPOINTMENT.
*(PRE-AUTHORIZATION-REFERRAL FROM PRIMARY
M.D. IS NEEDED FOR SOME HOSPITAL-MEDICAL
INSURANCE COMPANIES PRIOR TO YOUR VISIT).


                                                 1
      CANCELLATION POLICY




All cancellations including scheduled

procedures and office visits are subject to a

$25.00 cancellation fee, if not done before close

of business the day prior to your appointment.




                                                    2
                              PAIN QUESTIONNAIRE – INITIAL VISIT


NAME: __________________________________                  DATE: ________________________________
ADDRESS: _______________________________                  SSN: _________________________________
CITY: ___________________________________                 HOME PHONE: _______________________
SEX: ____      AGE: ____ D.O.B_____________               WORK PHONE: _______________________
Name of person who referred you to us: ________________________________________________
Relationship to you: [ ] Physician     [ ] Friend   [ ] Dentist   [ ] Counselor    [ ] other
Physician: _______________________________                Phone: _________________________________
Address: ___________________________________________________________________________
Specialty: (i.e. Internist, Family Practice) _______________________________________________
Shall we send him/her a report?       [ ] Yes   [ ] No
Your evaluation and treatment is paid for by: (Check all that apply):
[ ] Worker’s Comp.      [ ] Private Insurance Company       [ ] State (if so which state) _____
[ ] Self   [ ] Family   [ ] Friend
If your chief complaint is anything other than pain, please explain: ___________________________
____________________________________________________________________________________
____________________________________________________________________________________


                                     HISTORY OF PRESENT ILLNESS
Where is your pain located? (Check Areas That Apply)
[ ] Lower Back [ ] Mid-Back [ ] Upper Back [ ] Neck [ ] Chest [ ] Abdomen [ ] Groin
[ ] Left-Buttock [ ] Right-Buttock [ ] Left Thigh [ ] Right Thigh [ ] Left Leg          [ ] Right Leg
[ ] Left Ankle or Foot [ ] Right Ankle or Foot [ ] Left Shoulder [ ] Right Shoulder
[ ] Right Hand or Wrist [ ] Left Hand or Wrist [ ] Head [ ] Face [ ] Pelvic Area [ ] Rectal
[ ] Vaginal [ ] Mouth [ ] Hips


How long have you had this pain? __________________________________________________




                                                                                                    3
Please indicate on the diagram below where your pain occurs by shading in the painful area (s).




       When did you first notice your pain? (Month)_________ (Day) __________ (Year)
       ___________
Under what circumstances did your pain begin?             (check one that applies)
[ ] Accident at work [ ] Accident at home [ ] at work, but not an accident
[ ] Pain just began, no reason [ ] Motor vehicle accident [ ] Following Surgery
[ ] Following Illness [ ] other (please specify) _________________________________________


If pain began at work, please list the following:
Place of Employment where pain began: ________________________________________________
Date of Injury (MM/DD/YEAR):______________________________________________________
How long have/had you been employed there? (YRS/MOS):________________________________



                                                                                                  4
Type of Work? ______________________________________________________________________


Please indicate on the diagram below where your pain occurs by shading in the painful area (s).




When did you first notice your pain? (Month)_________ (Day) __________ (Year) ___________
Under what circumstances did your pain begin?             (check one that applies)
[ ] Accident at work [ ] Accident at home [ ] at work, but not an accident
[ ] Pain just began, no reason [ ] Motor vehicle accident [ ] Following Surgery
[ ] Following Illness [ ] other (please specify) __________________________________________


If pain began at work, please list the following:
Place of Employment where pain began: ________________________________________________
Date of Injury (MM/DD/YEAR):______________________________________________________
How long have/had you been employed there? (YRS/MOS):________________________________



                                                                                                  5
Type of Work? ______________________________________________________________________
If you were injured at work, describe how: (check the one that applies)
[ ] Fall [ ] Lifting [ ] Pushing [ ] Struck by fallen object [ ] Struck by object
[ ] Injury from repetitive activity [ ] Other (describe)
________________________________________

If injury resulted from a motor vehicle accident, were you:
[ ] Driving Automobile/Truck [ ] Passenger in Automobile/Truck
[ ] Motorcycle Operator [ ] Motorcycle Passenger [ ] Pedestrian
(describe details)____________________________________________________________________

When did you first see a doctor for the pain you have now?
(Month)__________ (Day) __________ (Year) __________

Approximately how many physicians have you seen for your pain in the last year? _________________

Have you had any of the following?
[ ] X-Rays [ ] Myelograms [ ] EMG [ ] Bone Scan [ ] MRI [ ] CAT Scan
[ ] Other (describe) ____________________________________________________________________

Circle the number that best describes your pain. 0 = no pain, 10 = worst pain
1     2      3   4      5     6     7     8      9     10

Does your pain vary in intensity? [ ] Yes [ ] No

The worst pain you ever have is (from 0 – 10) is _________

The least pain you ever have is (from 0 – 10) is _________

Would you best describe your pain as?
[ ] Burning [ ] Sharp [ ] Aching [ ] Throbbing [ ] Shooting
[ ] Other (please describe)

Which statement best describes your pain?
[ ] Always present and same intensity.
[ ] Always present, Intensity varies.
[ ] Usually present, but has short periods without pain.
[ ] Often present, but have free periods lasting one to several hours.
[ ] Often present, but am pain free most of the day.
[ ] Occasionally present, have pain once to several times per day, lasting a few minutes up to an hour.
[ ] Occasionally present for brief periods, a few seconds to a few minutes.




                                                                                                 6
What time of the day is your pain at its worst?     (check all that apply)
[ ] Morning on arising. [ ] Later in the Morning [ ] Afternoon [ ] Evening [ ] Bedtime [ ] Night
[ ] Pain is always the same. [ ] Other (describe) ____________________________________________


Do you have?
[ ] Numbness [ ] Tingling [ ] Pins & Needles [ ] Weakness [ ] Coldness [ ] Increased Swelling
[ ] Muscle Spasm [ ] Tightness [ ] Skin Discoloration [ ] Bowel or Bladder Problems


Circle the items in which increase your pain:
[ ] Sitting [ ] Worry/Stress [ ] Driving [ ] Standing/Walking [ ] Weather [ ] Time of Day
[ ] Alcohol [ ] Drugs [ ] Sex [ ] Physical Activity [ ] Being around [ ] Lying down


Circle the items which decrease your pain:
[ ] Rest/Bed [ ] Walking/Standing [ ] Sexual Activity [ ] Drugs/Alcohol [ ] Time of Day
[ ] Lying down [ ] Being around people [ ] Physical Activity


Nothing I do makes my pain feel any better: (TRUE) Or (FALSE)
How many hours per day (average) must you lie down because of pain?__________
How many times per day (average) must you stop what you are doing due to pain?_________
Do you have trouble falling asleep? [ ] Never [ ] Sometimes [ ] Usually [ ] Always
Does pain frequently awaken you? (YES) Or (NO)
If yes, how many times a night? ______________
When awakened do you:
[ ] Empty Bladder [ ] Sit up a while [ ] Take Medication [ ] Other
(Describe)___________________________________________________________________________
Do you easily return to sleep? (YES) Or (NO)


Has pain interfered with your desire for social life?
   [ ] No Interference [ ] Minimal Change [ ] Considerable Change [ ] Prevents


 Has pain interfered with your ability for social life?



                                                                                            7
   [ ] No Interference [ ] Minimal Change [ ] Considerable Change [ ] Prevents
Has pain interfered with your desire for hobbies or recreation?
   [ ] No Interference [ ] Minimal Change [ ] Considerable Change [ ] Prevents
Has pain interfered with your ability for hobbies or recreation?
   [ ] No Interference [ ] Minimal Change [ ] Considerable Change [ ] Prevents
Has pain interfered with your sexual desire?
   [ ] No Interference [ ] Minimal Change [ ] Considerable Change [ ] Prevents
Has pain interfered with your sexual ability?
   [ ] No Interference [ ] Minimal Change [ ] Considerable Change [ ] Prevents
Do you feel helpless to change your present condition?
   [ ] Never [ ] Sometimes [ ] Most of the time [ ] All of the time
Do you ever feel your condition is hopeless?
   [ ] Never [ ] Sometimes [ ] Most of the time [ ] All of the time
Do you think the pain is due to something more serious or different than what the doctors have told you?
   [ ] Yes [ ] No [ ] Not Sure
What do you think is the cause of your symptoms? __________________________________________
Have doctors ever suggested that your pain was imaginary or “all in your head”.
   [ ] Yes [ ] No
Have doctors or nurses ever acted as if you were faking the pain?
   [ ] Yes [ ] No
Other than medical problems and loss of income, are there any stressful situations in your life?
   [ ] Yes [ ] No
Does stress increase your pain?
   [ ]Yes [ ] No [ ] Have no Stress
Since your pain began has it?
   [ ] Increased [ ] Decreased [ ] Stayed the same
Rate your ability to cope with your pain by checking the choice which most closely reflects your
feelings.
   [ ] Totally unable to cope [ ] Limited ability to cope [ ] Fair ability to cope [ ] Cope Very Well




                                                                                                   8
                                      Previous Treatment and Results
       Check how often you use the following:
       Walker                      [ ] Never    [ ] Sometimes    [ ] Usually/Often
       Cane                        [ ] Never    [ ] Sometimes    [ ] Usually/Often
       Wheelchair                  [ ] Never    [ ] Sometimes    [ ] Usually/Often
       Brace                       [ ] Never    [ ] Sometimes    [ ] Usually/Often
       Neck Collar                 [ ] Never    [ ] Sometimes    [ ] Usually/Often
Have you ever had surgery for your pain problems?       [ ] Yes [ ] No
Have you ever had nerve blocks for your pain problems? [ ] Yes [ ] No How Many _____
       List the types and dates: ________________________________________
                               ________________________________________
                               ________________________________________
Did any block produce pain relief? [ ] Yes [ ] No
What was the longest duration (if any) of pain relief following a nerve block? _____________




Hospitalizations/                      Had No          Lasting       Temporary       No            Made
Operations                 Dates      Treatment        Benefit         Benefit       Help          Worse
_______________/           _____          0               1               2           3             4
_______________/           _____          0               1               2           3             4
_______________/           _____          0               1               2           3             4
_______________/           _____          0               1               2           3             4
Nerve Blocks               _____          0               1               2           3             4
Nerve Stimulator           _____          0               1               2           3             4
Physical Therapy           _____          0               1               2           3             4
Have you been to physical therapy in the last 6 months? _____________________________________
Do you feel physical therapy is helping with your current condition? __________________________
Which facility do/ did you attend? _______________________________
Have you had any steroids or steroid treatments of any kind in the last year? ______________________


Biofeedback/Hypnosis       _____          0               1               2           3             4


                                                                                               9
Acupuncture                  _____            0               1                2         3          4
Heating Pads, Ultrasound
Whirlpool, massage, etc.     _____            0               1                2         3          4
Manipulations                _____            0               1                2         3           4
Pain Management              _____            0               1                2         3           4
                                         General Medical History
Previous Hospitalizations, Serious Illness
Year        Diagnosis                                             Operation (if any)
____        ____________________________________                  ________________________________
____        ____________________________________                  ________________________________
____        ____________________________________                  ________________________________
Medications: List all prescription, non – prescription medications as well as vitamins that you have been
taking recently. Indicate the amount that you usually take.
1. ________________________________               5. ________________________________
2. ________________________________               6. ________________________________
3. ________________________________               7. ________________________________
4. ________________________________               8. ________________________________
List Medication that you have tried in the past for pain relief: __________________________________
____________________________________________________________________________________
Allergies: (Medications or other substances) ________________________________________________
____________________________________________________________________________________
Is there a history of any of the following in a blood relative?
         [ ] Alcoholism [ ] Migraine [ ] Chronic Pain [ ] Stroke [ ] Diabetes [ ] Heart Attack
         [ ] High Blood Pressure [ ] Breast Cancer [ ] Disability [ ] Depression
         [ ] Psychiatric Illness [ ] Colon Cancer [ ] Other ________________________________
X- Ray Studies: Please list the date and result of any x- rays you have had.
                  Year               Result
Chest             _________          _______________________________________________________
Kidney             _________         _______________________________________________________
Stomach            _________         _______________________________________________________
Gallbladder        _________         _______________________________________________________



                                                                                               10
Large Bowel       _________          _______________________________________________________
Mammogram         _________          _______________________________________________________
Myelogram         _________          _______________________________________________________
MRI/ MMR of
Spine or head     _________          _______________________________________________________
Check any conditions that you have ever had.
[ ] Heart Attack      [ ] Thyroid Trouble          [ ] Easy Bruising         [ ] High Blood Pressure
[ ] Diabetes         [ ] Joint disease/Arthritis   [ ] Heart Murmur          [ ] Ulcer/Stomach Problems
[ ] Rheumatic Fever [ ] Skin Rash                  [ ] Asthma/Bronchitis      [ ] Hiatal Hernia
[ ] Phlebitis        [ ] TB/Lung Disease           [ ] Bowel Problems        [ ] Discharge from Penis/Urethra
[ ] Pnuemonia        [ ] Kidney Problems           [ ] Stroke                [ ] Bladder Problems
[ ] Gonorrhea        [ ] Seizure                   [ ] Hepatitis             [ ] Liver Disease/Jaundice
[ ] Herpes           [ ] Paralysis                 [ ] Syphilis              [ ] Polio
[ ] Bleeding Problems                              [ ] Psychiatric Illness    [ ] Learning Problems

Personal Habits
Do you smoke? (YES) Or (NO) if yes then what type of tobacco_____      how much per day _____
If no, are you a previous smoker? (YES) Or (NO)
Do you drink alcohol? If yes how much? __________________________________________________
Have you ever had a problem with alcohol? (Yes) Or (NO)
Mow many Coffee, Tea or Cola Beverages do you drink a day. _________________________________

Have you had any of the following?                                           YES            NO
1. Recent weight gain? (______ pounds)                                        []             []
2. Recent weight loss? (______ pounds)                                        []             []
3. Fever or Soaking sweats at night?                                          []             []
4. Fatigue?                                                                  []              []
5. Treatment with X-Ray’s?                                                    []             []
6. Weakness or numbness of arms or legs?                                      []             []
7. Headaches (more than 1 or 2 p/week)?                                      []              []
8. Difficulty walking?                                                        []             []
9. Loss of conciousness or convulsions?                                       []             []
10. Problem with vision not corrected with glasses?                           []             []
11. Impaired hearing?                                                         []             []
12. Dizziness?                                                                []             []
13. Frequent or sever nose bleeds?                                            []             []
14. Trouble chewing?                                                          []             []


                                                                                                    11
15. Sore tongue or mouth?                                  []           []
16. Daily cough?                                           []           []
17. Shortness of breath after 2 flights of stairs?         []           []
18. Shortness of breath just sitting or lying down?        []           []
19. Discomfort in the chest?                               []           []
20. Swelling of the ankles every day?                      []           []
21. Abdominal Pain                                         []           []
22. Frequent heartburn or indigestion?                     []           []
23. Change in bowel habits?                                []           []
24. Black or bloody bowel movement?                        []           []
25. Bloody or unusual appearing urine?                     []           []
26. Difficulty urinating?                                  []           []
27. Do you lose control of urine at times?                 []            []
28. Awaken at night more than once to urinate?             []            []
29. Any skin problems at this time?                        []            []
30. Persistent pain in joints?                              []           []
31. Back Pain?                                             []            []
32.Frequent conflicts at home?                             []            []
33. Sexual Problems?                                       []            []
34. Do you feel anxious or depressed?                      []            []
35. Have you seriously considered suicide?                 []            []
36.History of hospitalizations for emotional problems?     []            []


Female patients only                                       Yes          NO
37. Are menstrual periods normal?                          []            []
38. Date of last menstrual period?                         Mo____ Day____ Year_____
39. Any vaginal discharge?                                 []            []
40. Any breast discharge?                                  []            []
41. Bleeding between menstrual cycle or after menopause?   []            []
42. Appx. Date of last pap smear?                          Mo____ Day____ Year_____
43. # of Pregnancies______       # of Deliveries_____



                                                                              12
How often do you see a doctor?
[ ] 3 or more times a month [ ] 1-2 times a month [ ] Less than once a month
Other than your pain problems, are you frequently ill. [ ] Yes          [ ] No
                                                 Social History


Circle years of school completed: 6, 7, 8, 9, 10 , 11, 12, 13, 14, 15, 16, 17, 18, 19
Marital Status: Single      Married      Widowed         Divorced     Seperated     Remarried
Number of Children? ___________________ Ages? _____________________
Who shares your home? ____________________________________________
If married, rate your marital relationship?
[ ] Excellent   [ ] Good   [ ] Ok-Fair   [ ] Not Good, but tolerable [ ] Barely Tolerable
Check the causes of major marital conflicts:
[ ] Finances [ ] Work-Situation     [ ] Religion [ ] Children [ ] Personality Difference
[ ] Parents/ In-Law [ ] Alcohol/Drugs [ ] Sex [ ] Illness [ ] House environment
Other___________________________________________________________________
Spouse’s Occupation ______________________________________________________
How many people are supported by the family income? __________________________


                                           Occupational History
Occupation_____________________________               How long at this position ___________________
Breif description of your usual job duties________________________________________________
Work Status: [ ] Full Time [ ] Part Time [ ] Student [ ] Disabled [ ] Unemployed [ ] Retired
If disabled, ( as worker, student, homemaker), date last worked? _____________________________
If working less than full time, is pain is the reason?              (Yes) or (NO)
If disabled, have you tried to return to work?                      (Yes) or (NO)    (Full) or (Part-Time)
Did your employer allow you to return?                              (Yes) or (No)
Do you think that you can work at your regular job?                 (Yes) or (No)     (Full) or (Part-Time)
If you had no pain would you return to work?                        (Yes) or (No)
How would you rate your enjoyment of your usual job? ____________________________________



                                                                                                    13
Your job provides a sense of satisfaction?
[ ] Rarely/Never [ ] Occasionally [ ] Fairly often [ ] Usually [ ] Always
Do you feel you are fairly paid when working?                    (Yes) or (No)




Has your employer been helpful and understanding of your problem? (Yes) (No) (Not sure)
Since your injury/illness, has your employer treated you fairly?         (Yes) (No) (Not sure)


                                             General Questions
What do you hope will be the end result of this evaluation?
       [ ] Medical diagnosis (discover the cause of pain)
       [ ] To determine the existence and/or extent of a disability
       [ ] Recommendation for surgery
       [ ] Recommendation for medications
       [ ] Recommendation for rehabilitation
       [ ] Other ___________________________________________________________________


If you are treated here, what are the results you hope for?
       [ ] Pain reduction
       [ ] Increased recreation
       [ ] Improved emotional well-being
       [ ] Increased socialization
       [ ] Return to work
       [ ] Elimination of drugs
       [ ] Other ____________________________________________________________________


If you are treated here, what are the results you EXPECT? _________________________________
_________________________________________________________________________________
If your treatment here does not bring you relief , do you think you will try elsewhere?   (Yes) (No)




                                                                                               14
Please circle the words which describe your pain. Leave out any word group that is not suitable. Use
only a single word in each group. Use the one that best applies to you. You do not have to use a word in
any group.


       1.                      2.                     3.                     4.
1. Flickering            1. Dumping             1. Prickling             1. Sharp
2.Quivering              2. Flashing             2. Boring               2. Cutting
3. Pulsing               3. Shooting            3. Drilling              3. Lacerating
4. Throbbing                                    4. Lancinating
5. Bearing
6. Pounding

       5.                     6.                      7.                      8.
1. Pinching              1. Tugging             1. Hot                  1. Tingling
2. Pressing              2. Pulling             2. Burning              2. Itchy
3. Gnawing               3. Wrenching           3. Scalding             3. Smarting
4. Cramping                                     4. Searing              4. Stinging
5. Crushing

     9.                        10.                   11.                      12.
1. Tender                 1. Tiring               1. Sickening            1. Fearful
2 .Taut                   2. Exhausting           2. Suffocating         2. Frightful
3. Rasping                                                               3. Terrifying

   13.                        14.                    15.                     16.
1. Punishing              1.Wretched              1. Annoying            1. Spreading
2. Grueling               2. Blinding             2. Troublesome         2. Radiating
3. Cruel                                          3. Miserable           3. Penetrating

   17.                         18.                    19.
1. Tight                  1. Cool                 1. Nagging
2. Numb                   2. Cold                 2. Nauseating
3. Dawing                 3. Freezing             3. Agonizing
4. Squeezing                                      4. Dreadful




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