PATIENT INTAKE FORM
NAME DATE OF BIRTH Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ADDRESS AGE SEX    Male      Female CITY STATE ZIP  HOME PHONE WORK PHONE SECONDARY NOTIFICATION: NAME AND RELATIONSHIP PHONE NO

 

	SOCIAL HISTORY
MARITAL STATUS MARRIED SINGLE WIDOWED DIVORCED DO YOU SMOKE? YES NO HOW MUCH? DO YOU DRINK ALCOHOLIC BEVERAGES? YES NO HOW MUCH? HAVE YOU EVER RECEIVED TREATMENT FOR ANY TYPE OF ADDICTION? YES NO IF YES, DESCRIBE: ARE YOU PREGNANT OR PLAN TO BECOME PREGNANT? YES NO WHAT TYPE OF EXERCISES/HOBBIES DO YOU LIKE? DOES YOUR PAIN INTERFERE WITH THESE HOBBIES? YES NO IF YES, HOW? NAME OF EMPLOYER: OCCUPATION: WHAT WORK DO YOU DO? WHAT DOES YOU WORK INVOLVE? HOW MANY HOURS DO YOU WORK PER WEEK? HOW MUCH WORK HAVE YOU MISSED IN THE PAST MONTH DUE TO PAIN?

 

	PAIN HISTORY
DESCRIBE IN YOUR OWN WORDS WHAT YOU PAIN IS LIKE (WHERE IT IS, HOW IT FEELS, IS IT CONSTANT, DOES IT COME AND GO, ETC.) HOW LONG HAVE YOU HAD THIS PROBLEM?

 

	PREVIOUS TREATMENT FOR PAIN
HELPFUL PLEASE CHECK ONE YES NO YES NO   NERVE BLOCKS NAME OF PHYSICIAN:           DATE: SURGERY NAME OF SURGEON: TENS UNIT COMMENTS: OCCUPATIONAL/PHYSICAL THERAPY NAME OF THERAPIST: BIOFEEDBACK NAME OF THERAPIST: HYPNOSIS NAME OF THERAPIST: COUNSELING NAME OF THERAPIST: CHIROPRACTOR NAME OF CHIROPRACTOR: WHICH TYPE OF THE FOLLOWING TESTS HAVE YOU HAD TO EVALUATE YOUR PAIN PROBLEM WITHIN THE PAST 6 MONTHS TO A YEAR? PLEASE LIST THE APPROXIMATED DATE OF TEST, THE NAME OF THE FACILITY WHERE THE TEST WAS PERFORMED, THE NAME OF THE ORDERING PHYSICIAN AND THE RESULTS, IF KNOWN. TEST DATE FACILITY PHYSICIAN RESULTS X-RAY NORMAL ABNORMAL CT SCAN NORMAL ABNORMAL MRI NORMAL ABNORMAL LABORATORY NORMAL ABNORMAL EMG NORMAL ABNORMAL MYELOGRAM NORMAL ABNORMAL RECTAL/HEMOCCULT NORMAL ABNORMAL BONE SCAN NORMAL ABNORMAL

 

	MEDICAL HISTORY
WEIGHT   HEIGHT CHECK ANY OF THE FOLLOWING CONDITIONS THAT YOU HAVE HAD OR PRESENTLY HAVE AND NOTE WHEN IT WAS DIAGNOSED.  CONDITION  DATE DIAGNOSED  CONDITION  DATE DIAGNOSED  Diabetes Emphysema Asthma Allergies Cancer Ulcer Arthritis Kidney Problems High Blood Pressure Bleeding Disorder Heart Problems Seizure Disorder Psychological Disorders Anxiety Disorder Other: Other: Comments: LIST ANY SURGERIES YOU HAVE HAD: TYPE OF SURGERY   DATE:    ARE YOU ALLERGIC TO ANY MEDICATIONS? IF YES, WHICH ONES?     ARE YOU ALLERGIC TO LATEX PRODUCTS? YES NO   ARE YOU TAKING BLOOD THINNING MEDICATION?  YES   NO  IF SO, PLEASE LIST       CURRENT MEDICATIONS: WHAT MEDICATIONS, IF ANY, ARE YOU TAKING NOW. PLEASE LIST  ALL MEDICATIONS BOTH PRESCRIPTION AND OVER THE COUNTER. MEDICATION WHY PRESCRIBED DOSAGE EFFECTIVENESS

 

LITIGATION:  IF YOUR PAIN IS DUE TO AN ACCIDENT, IS LITIGATION (LEGAL SUIT) OR AN INSURANCE SETTLEMENT PENDING?  DO YOU HAVE PLANS TO PURSUE A LEGAL OR INSURANCE SETTLEMENT IN THE FUTURE? IF YES TO EITHER QUESTION, PLEASE DESCRIBE:

 

	RELEASE OF RECORDS
I GIVE PERMISSION TO The Pain Institute, TO OBTAIN COPIES OF MY RECORDS, DIAGNOSTIC PROCEDURES, ETC., FROM PREVIOUS TREATING PHYSICIANS AND FACILITIES THAT MAY BENEFIT IN THE UNDERSTANDING AND TREATMENT OF MY CURRENT CONDITION. NAME: DATE: