Metro Anesthesia & Pain Management
NAME______________________________BIRTH DATE_____________AGE ________DATE___________________
REFERRING DOCTOR________________________________FAMILY DOCTOR_____________________________
Where is your pain? _________________________________________________________________________________
Does your pain radiate to anywhere? ______________________ ____________________________________________________ When did your pain begin? ______________________________ What caused your pain? (work related, fall, car accident, spontaneous, ect.) ____________________________________________________
Describe your pain pattern: constant
Please rate your pain by circling the one number that best describes your pain at its WORST in the last 24 hours:
Please rate your pain by circling the one number that best describes your pain at its LEAST in the last 24 hours:
Please rate your pain by circling the one number that best describes your pain on the AVERAGE:
Please rate your pain by circling the one number that tells how much pain you have RIGHT NOW:
Please use the following scale to choose the one number that describes how, in recent time, pain has interfered with your:
Normal Work (includes both work outside the home and housework)__________ Describe your pain: (Circle appropriate response) burning
Aggravating events: (Circle appropriate response) standing
other___________________________________________________
Please circle all medications that you have tried for this problem: Anti-inflammatories (Motrin, Aleve, Aspirin, etc.) Tylenol
Hydrocodone Avinza Duragesic/Fentanyl Patch
Other:___________________________________________________________________________________ Please circle all treatments that you have previously received or are currently receiving for this problem: Epidural Injection
Surgery Spinal Cord Stimulator/Intrathecal Pump
Other: __________________________________________________________________________________ What has helped your pain in the past? ___________________________________________________________ Previous Testing X-Ray
List all physicians who have treated you for your pain and approximate dates.
_______________________________________________________________
_______________________________________________________________
Have you been evaluated previously by a pain specialist?
_______________________________________________________________
_______________________________________________________________
Please answer the following questions as honestly as possible. This information is for our records and will remain confidential. Your answers alone will not determine your treatment. Please use the following scale when answering the following questions: 0=Never, 1=Seldom, 2=Sometimes, 3=Often, 4=Very Often
2. How often do you smoke a cigarette within an hour after you wake up?
3. How often have you taken medication other than the way that it was
prescribed? 4. How often have you used illegal drugs (for example, marijuana,
cocaine, etc.) in the past five years? 5. How often, in your lifetime, have you had legal problems or been
Past Medical History:
other:___________________________________________________________________________
Past Surgical History:
other: __________________________________________________________________________
Medication Allergies: ___________________________________________________________________ Do you take a blood thinner (Lovenox, Coumadin, Plavix, Aggrenox, Pletal, Effient, Pradaxa, Xarelto, Aspirin…)? Yes or No Current Medications: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Who currently prescribes your pain pills? _____________________________________________________________ Past Family History: Has any blood relative had any of the following (please circle) and who? Coronary Artery Disease __________________Hypertension __________________ Heart Attack __________________ Diabetes _________________Cancer _________________ Stroke __________________ Seizures _________________ Bleeding Disorders _______________ Psychiatric History _______________ Alcohol/Substance Abuse _____________ Other: ___________________________________________________________________________________________ Marital status: Married ( ) Single ( ) Divorced ( ) Widowed ( ) List people whom you live with, relationship, and their health _____________________________________________________________________________ Do you smoke? __________ How much? _________ When did you quit? ___________________________ Do you drink alcohol? (circle) Never
Do you drink caffeine? _______________ How much? _________________________________________ Are you currently using any recreational or street drugs? (Circle Yes if used within the past year) Yes or No Have you ever abused or had an addiction to drugs or alcohol? Yes or No Have you ever received treatment for drug or alcohol abuse? Yes or No Current employer: ___________________________________ Full-Time ______Part-Time ______Homemaker______
Complete Review of Systems: Please circle any difficulty or problem you have experienced within the past month: General: Chills, Fever, Night Sweats, Fatigue, Trouble Sleeping, Weight Loss or Gain Integumentary: New Lesions, Rashes, Itching, Skin Color Changes, Hair and Nail Changes Head/Eyes/Ears/Nose/Throat: Headache, Visual Disturbances, Vision Loss, Deafness, Decreased Hearing Respiratory: Shortness of Breath, Cough, Decreased Exercise Tolerance Cardiac: Chest Pain, Hypertension, Difficulty Breathing Lying Down, Racing Heart, Shortness of Breath, Swelling Gastrointestinal: Change in Bowel habits, Constipation, Diarrhea, Nausea, Vomiting Musculoskeletal: Neck Pain, Back Pain, Muscle Spasms, Joint Pain, Muscle Pain Neurologic: Incontinence Stool, Incontinence Urine, Numbness, Tingling, Weakness Psychiatric: Anxiety, Depression, Bipolar, Schizophrenia, Suicidal Thoughts, Substance Abuse Hematologic: Prolonged Bleeding, Spontaneous Bleeding
Europeiska ekonomiska och sociala kommittén "Arbetstagarnas ekonomiska delaktighet inom EU" YTTRANDE från Europeiska ekonomiska och sociala kommittén "Arbetstagarnas ekonomiska delaktighet inom EU" Föredragande: Alexander Graf von Schwerin Medföredragande: Madi Sharma SOC/371 – CESE 1375/2010 DE/EXTERN-MKE-Sv/HF1-PH-ES/ad-mp-hh Rue Belliard
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Metro Anesthesia & Pain Management