Pain Management Center

HEALTH ASSESSMENT Pain Management Center

Page 4 of 4
HEALTH ASSESSMENT
Page 1 of 4
Review of Symptoms:
Headache YES NO Diarrhea YES NO DATE:
Palpitations YES NO Bladder/Bowel YES NO NAME: DOB:
Chronic Cough YES NO Incontinence YES NO REFERRING MD: PRIMARY MD:
Heartburn YES NO Heat Tolerance YES NO
ADDRESS: ADDRESS:
Blood in Urine YES NO Weakness YES NO
Thrist/Polyuria YES NO Shortness of Breath YES NO
Visual Problems YES NO Constipation YES NO PHONE: PHONE:
Chest Pain YES NO Swelling YES NO
Chief Complaint:
Wheezing YES NO Other YES NO
Please briefly state the main reason you are here today. For example: low back pain, headache, right shoulder pain, etc.
This is the end of the patient section, the rest of the information will be filled in by your doctor or nurse.

History of Illness:
Patient Signature: Date:
When did the pain first start?
Pre-Procedure Evaluation How did your pain start?
History of present Illness: Was it the result of an accident or injury? YES NO
Are you involved in litigation (a lawsuit?) YES NO
Is Worker’s Compensation involved in your injury? YES NO
Does the pain radiate from this part of your body to another area? If yes, where?

Please check the words that best describe your pain:

BP: Pulse: Ht: Wt: VNS: ACHING HOT SHOOTING
SHARP COLD NAGGING
Physical Exam: BURNING NUMB SEVERE
STABBING TINGLING OTHER:
Airways: Lung: Heart: ASA:
Please indicate on the chart where your pain is:

Musculoskeletal:

Neurological:

Diagnosis:

CL0300
Plan of Procedure:

FRONT BACK LEFT SIDE RIGHT SIDE

Please circle the number on the scale of 0 - 10 that represents your pain:
0 1 2 3 4 5 6 7 8 9 10
no pain severe pain
X , MD _____/_____/_____ ___ ___ : ___ ___ PC 007 10/12
Signature Pager # Date Time
Pain Management Center Pain Management Center
HEALTH ASSESSMENT HEALTH ASSESSMENT
Page 2 of 4 Page 3 of 4

Date: Date:
Is your pain constant or intermittent? Constant Intermittent Past Medical History:
If your pain is intermittent, is there a time of day when your pain is usually worse or better? Do you have history of any of the following?
Worse AM/PM Better AM/PM Chest Pain YES NO Stroke YES NO
Are there activities which make your pain worse (example: walking, sitting, stair climbing, etc.)? Heart Attack YES NO Ulcer Disease YES NO
High Blood Pressure YES NO Diabetes YES NO
What makes your pain better? Congestive Heart Failure YES NO Thyroid Problem YES NO
Abnormal Heart Rhythm YES NO Anemia YES NO
Asthma YES NO Bleeding Disorders YES NO
Please check any diagnositc tests you have had for this condition:
Pneumonia YES NO Arthritis YES NO
MRI CAT SCAN EMG OTHER: Kidney Failure YES NO Psychiatric Disorder YES NO
Please check any treatment you have had for pain: Prostate Trouble YES NO Cancer YES NO
Liver Failure YES NO HIV YES NO
ACUPUNCTURE NERVE BLOCK or other STEROID INJECTIONS
Hepatitis YES NO Are You Pregnant YES NO
CHIROPRACTOR PHYSICAL / AQUA THERAPY
Seizure YES NO
HEAT / COLD SURGERY
MASSAGE TENS Past Surgical History:
MEDICATIONS OTHER: Check this box if you have never had surgery.
Please list any surgical procedures that you have had and the date of surgery
Current Medications: Surgery: Date of operation:
All other medications not for pain.
Medication: Amount (mg.) Frequency What is it for?

Family History:
Please list any diseases that run in your family, for example; diabetes, heart disease, cancer, etc.

Pain Medications:
Please list any pain medications you are taking now or have in the past to treat your pain.
Medication: Amount Has it Helped? Prescribed by:
Social History:
YES NO
Do you smoke? YES NO If so how much?
YES NO Do you drink alcohol YES NO If so how much?
YES NO Have you ever had a problem with alcoholism? YES NO
CL0300

CL0300
Do you have any history of using Marijuana, Cocaine, Heroin, or any other illegal drugs? YES NO
YES NO
If yes which drugs?
YES NO
Marital Status: single married divorced widowed committed relationship
Allergies: Work Status: working not working retired disabled
Check this box if you have no known drug allergies. Disability: temporary permanent
Please list any medications that you are allergic to and the adverse reaction you have. Reason for disability:
Medication: Adverse reaction
Pain Management Center Pain Management Center
HEALTH ASSESSMENT HEALTH ASSESSMENT
Page 2 of 4 Page 3 of 4

Date: Date:
Is your pain constant or intermittent? Constant Intermittent Past Medical History:
If your pain is intermittent, is there a time of day when your pain is usually worse or better? Do you have history of any of the following?
Worse AM/PM Better AM/PM Chest Pain YES NO Stroke YES NO
Are there activities which make your pain worse (example: walking, sitting, stair climbing, etc.)? Heart Attack YES NO Ulcer Disease YES NO
High Blood Pressure YES NO Diabetes YES NO
What makes your pain better? Congestive Heart Failure YES NO Thyroid Problem YES NO
Abnormal Heart Rhythm YES NO Anemia YES NO
Asthma YES NO Bleeding Disorders YES NO
Please check any diagnositc tests you have had for this condition:
Pneumonia YES NO Arthritis YES NO
MRI CAT SCAN EMG OTHER: Kidney Failure YES NO Psychiatric Disorder YES NO
Please check any treatment you have had for pain: Prostate Trouble YES NO Cancer YES NO
Liver Failure YES NO HIV YES NO
ACUPUNCTURE NERVE BLOCK or other STEROID INJECTIONS
Hepatitis YES NO Are You Pregnant YES NO
CHIROPRACTOR PHYSICAL / AQUA THERAPY
Seizure YES NO
HEAT / COLD SURGERY
MASSAGE TENS Past Surgical History:
MEDICATIONS OTHER: Check this box if you have never had surgery.
Please list any surgical procedures that you have had and the date of surgery
Current Medications: Surgery: Date of operation:
All other medications not for pain.
Medication: Amount (mg.) Frequency What is it for?

Family History:
Please list any diseases that run in your family, for example; diabetes, heart disease, cancer, etc.

Pain Medications:
Please list any pain medications you are taking now or have in the past to treat your pain.
Medication: Amount Has it Helped? Prescribed by:
Social History:
YES NO
Do you smoke? YES NO If so how much?
YES NO Do you drink alcohol YES NO If so how much?
YES NO Have you ever had a problem with alcoholism? YES NO
CL0300

CL0300
Do you have any history of using Marijuana, Cocaine, Heroin, or any other illegal drugs? YES NO
YES NO
If yes which drugs?
YES NO
Marital Status: single married divorced widowed committed relationship
Allergies: Work Status: working not working retired disabled
Check this box if you have no known drug allergies. Disability: temporary permanent
Please list any medications that you are allergic to and the adverse reaction you have. Reason for disability:
Medication: Adverse reaction
Pain Management Center
HEALTH ASSESSMENT Pain Management Center
Page 4 of 4
HEALTH ASSESSMENT
Page 1 of 4
Review of Symptoms:
Headache YES NO Diarrhea YES NO DATE:
Palpitations YES NO Bladder/Bowel YES NO NAME: DOB:
Chronic Cough YES NO Incontinence YES NO REFERRING MD: PRIMARY MD:
Heartburn YES NO Heat Tolerance YES NO
ADDRESS: ADDRESS:
Blood in Urine YES NO Weakness YES NO
Thrist/Polyuria YES NO Shortness of Breath YES NO
Visual Problems YES NO Constipation YES NO PHONE: PHONE:
Chest Pain YES NO Swelling YES NO
Chief Complaint:
Wheezing YES NO Other YES NO
Please briefly state the main reason you are here today. For example: low back pain, headache, right shoulder pain, etc.
This is the end of the patient section, the rest of the information will be filled in by your doctor or nurse.

History of Illness:
Patient Signature: Date:
When did the pain first start?
Pre-Procedure Evaluation How did your pain start?
History of present Illness: Was it the result of an accident or injury? YES NO
Are you involved in litigation (a lawsuit?) YES NO
Is Worker’s Compensation involved in your injury? YES NO
Does the pain radiate from this part of your body to another area? If yes, where?

Please check the words that best describe your pain:

BP: Pulse: Ht: Wt: VNS: ACHING HOT SHOOTING
SHARP COLD NAGGING
Physical Exam: BURNING NUMB SEVERE
STABBING TINGLING OTHER:
Airways: Lung: Heart: ASA:
Please indicate on the chart where your pain is:

Musculoskeletal:

Neurological:

Diagnosis:

CL0300
Plan of Procedure:

FRONT BACK LEFT SIDE RIGHT SIDE

Please circle the number on the scale of 0 - 10 that represents your pain:
0 1 2 3 4 5 6 7 8 9 10
no pain severe pain
X , MD _____/_____/_____ ___ ___ : ___ ___ PC 007 10/12
Signature Pager # Date Time