Microsoft word - 2012 new pt quest.doc

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:

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)

Aggravating events: (Circle appropriate response)
other___________________________________________________ Please circle all medications that you have tried for this problem:
Anti-inflammatories (Motrin, Aleve, Aspirin, etc.)
Hydrocodone Avinza Duragesic/Fentanyl Patch

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
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:
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


Physical Exam

Vitals: BP

Assessment and Plan
Dictation conf. #________________________


Microsoft word - ces1375-2010_ac_sv

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