History and physical questionnaire Florida Institute of Pain

							                            History and Physical Questionnaire


Patient Name: ________________________________________________________________

Date of Birth: ________________________________

Which part of your body hurts the most?___________________________________________

How long have you had this pain? ________________________________________________

Please describe your level of pain: = NO pain and 10=WORST pain imaginable. Please circle below:

                            0 1 2 3 4 5 6 7 8 9 10
Please complete the pain diagram, shading the areas where you are experiencing pain.




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                                          History and Physical Questionnaire


         How would you describe the quality of your pain? Please check ALL words below that apply:

              Constant                                                               Cramping
              Brief                                                                  Shooting
              Aching                                                                 Radiating
              Excruciating                                                           Soreness
              Numbness                                                               Heaviness
              Sharpness                                                              Throbbing
              Dullness                                                               Stiffness:
              Stabbing                                                               Other:
              Burning                                                                Other:

         Does it interfere with your (circle all that apply): ��

         Work ��         Sleep ��       Daily Routine ��       Recreation                Other:____________
         ����������������������������
         Activities or movements that are painful to perform (circle all that apply):

         Sitting������Standing��������Walking��������Bending������Lying Down����������None

         Other___________________________________��������������������������������������

         What makes the pain better?____________________________________

         What make the pain worse?_____________________________________

                                 Please check any of the following that you have had for this pain issue:


Epidural Injections                                                                                            Yes      No

Nerve Blocks                                                                                                   Yes      No

Tens Units                                                                                                     Yes      No

Pain Medications                                                                                               Yes      No

Previous Pain Clinic Treatment                                                                                 Yes      No

Psychiatrist/Psychologist                                                                                      Yes      No

Physical Therapy/Massage Therapy                                                                               Yes      No

Chriopractor                                                                                                   Yes      No

Other:___________________________________________                                                              Yes      No


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                                     History and Physical Questionnaire


                 Please check any of the following DIAGNOSTIC STUDIES that you have had for this pain issue:


MRI Scan                                                                                                          Yes      No

XRAYS                                                                                                             Yes      No

CAT Scan                                                                                                          Yes      No

EMG/NCS                                                                                                           Yes      No

Discogram                                                                                                         Yes      No

Myelogram                                                                                                         Yes      No

Other:___________________________________________                                                                 Yes      No




Current medications
Name the Drug                             Strength                                   Frequency Taken




Allergies
Substance                                 Reaction




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                                    History and Physical Questionnaire


       Please list past or current medical problems.

                                            Circulatory/Vascular         HIV/HIDS
   Cancer                                                         
                                            Seizures                     Hepatitis
   Diabetes                                                       
                                            Neurological Probelms        Kidney Problems
   Heart Disease                                                  
                                            Headaches                    Thyroid Disease
   High Blood Pressure                                            
                                            Depression/Anxiety           Other:
   Stomach/GI Problems                                            
                                            Stroke
   Lung Disease                        




Surgeries
Year         Reason                                                     Hospital




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                             History and Physical Questionnaire


                                             REVIEW OF SYSTEMS

Constitional                Skin-                            Head-                        Ears-
□ Weight loss or gain       □ Rashes                         □ Headache                   □ Decreased hearing
□ Fatigue                   □ Lumps                          □ Head injury                □ Ringing in ears (tinnitus)
□ Fever or chills           □ Itching                                                     □ Earache
□ Weakness                  □ Dryness                                                     □ Drainage
□ Trouble sleeping          □ Color changes
                            □ Hair and nail changes

Eyes-                       Nose-                            Throat-                      Neck-
□ Vision                    □ Stuffiness                     □ Teeth                      □ Lumps
□ Glasses or contacts       □ Discharge                      □ Gum bleeding               □ Swollen glands
□ Redness                   □ Itching                        □ Sore tongue                □ Pain
□ Blurry or double vision   □ Hay fever                      □ Dry mouth                  □ Stiffness
□ Flashing lights           □ Nosebleeds                     □ Sore throat
□ Glaucoma                  □ Sinus pain                     □ Hoarseness
□ Cataracts

Respiratory-                Cardiovascular-                  Gastrointestinal-            Urinary-
□ Cough                     □ Chest pain or discomfort       □ Swallowing difficulties    □ Frequency
□ Coughing up blood         □ Tightness                      □ Heartburn                  □ Urgency
□ Shortness of breath       □ Palpitations                   □ Change in appetite         □ Burning or pain
□ Wheezing                  □ Shortness of breath            □ Nausea                     □ Blood in urine
□ Painful breathing                                          □ Change in bowel habits     □ Incontinence
                                                             □ Rectal bleeding            □ Change in urinary strength
                                                             □ Constipation
                                                             □ Diarrhea

Neurologic-                 Musculoskeletal-                 Endocrine-                   Psychiatric-
□ Dizziness                 □ Muscle or joint pain           □ Head or cold intolerance   □ Nervousness
□ Fainting                  □ Stiffness                      □ Sweating                   □ Depression
□ Seizures                  □ Back pain                      □ Frequent urination         □ Memory loss
□ Weakness                  □ Redness of joints              □ Thirst                     □ Stress
□ Numbness                  □ Swelling of joints             □ Change in appetite
□ Tingling                  □ Trauma                                                      Hematologic-
□ Tremor                                                                                  □ Ease of bruising
                                                                                          □ Ease of bleeding

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                                          History and Physical Questionnaire
                                                          FAMILY HEALTH HISTORY

                         AGE            SIGNIFICANT HEALTH PROBLEMS                              AGE          SIGNIFICANT HEALTH PROBLEMS
                                                                                             
                                                                          Children           M
   Father                                                                                    
                                                                                             F
                                                                                             
                                                                                             M
   Mother                                                                                    
                                                                                             F

                   M
                                                                          Grandmother
                   F
   Siblings
                   M
                                                                          Grandfather
                   F




                                                           SOCIAL HISTORY

Marital
Status         Single                   Married               Divorced                Seperated


               None                     Coffee                Tea                     Cola
Caffeine
              # of cups/cans per day?

              Do you drink alcohol?                                                                                       Yes      No
Alcohol
              If yes, what kind?

              How many drinks per week?

              Do you use tobacco?                                                                                         Yes      No
Tobacco                                                                                 
               Cigarettes – pks./day                           Chew - #/day           Pipe -    Cigars - #/day
                                                                                        #/day
               # of years               Or year quit




        _______________________________________                                      ___________________________

        Patient Signature                                                            Date



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