PAIN EVALUATION FORM
Today’s Date: ___________________
LAST NAME FIRST NAME MIDDLE
HOME PHONE CELL PHONE FAX #
DATE OF
BIRTH:
AGE SEX:
MALE ____ FEMALE ____
SS #
HEIGHT WEIGHT DOMINANT HAND:
RIGHT ________ LEFT ________
NAME OF REFERRING DOCTOR PHONE FAX
ADDRESS CITY STATE ZIP
NAME OF PHARMACY PHONE FAX
ADDRESS CITY STATE ZIP
II. Understanding Your Pain
A. Describe in your own words the pain problem(s) you would like help with:
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B. How often does your pain occur? C. How long does your pain last?
Continuous continuous
several times a day weeks
once per day days
several times per week hours
once per week minutes
less than once per week seconds
never none
D. Below is a list of words that may describe your pain. Please rate each word by placing a mark
in the column that describes the intensity of that type of pain:
None Mild Moderate Severe
Throbbing 0) 1) 2) 3)
Shooting 0) 1) 2) 3)
Stabbing 0) 1) 2) 3)
Sharp 0) 1) 2) 3)
Cramping 0) 1) 2) 3)
Gnawing 0) 1) 2) 3)
Hot-Burning 0) 1) 2) 3)
Aching 0) 1) 2) 3)
Heavy 0) 1) 2) 3)
Tender 0) 1) 2) 3)
Splitting 0) 1) 2) 3)
Sickening 0) 1) 2) 3)
Fearful 0) 1) 2) 3)
Punishing 0) 1) 2) 3)
Please rate your pain intensity, interference, distress, and sleep disturbance by using the scales below:
E. Circle a number below to indicate your highest pain intensity over the past week
0 1 2 3 4 5 6 7 8 9 10
No pain Mild pain Moderate pain Severe pain Most intense
pain imaginable
F. Circle a number below to indicate your lowest pain intensity over the past week
0 1 2 3 4 5 6 7 8 9 10
No pain Mild pain Moderate pain Severe pain Most intense
pain imaginable
G. Circle a number below to indicate your usual pain intensity over the past week
0 1 2 3 4 5 6 7 8 9 10
No pain Mild pain Moderate pain Severe pain Most intense
pain imaginable
H. Circle the number to indicate how much your pain has interfered with your activities this past week.
0 1 2 3 4 5 6 7 8 9 10
None Mild Moderate Severe Completely
I. Circle the number to indicate how distressed or bothered you have been in the past week about the pain.
0 1 2 3 4 5 6 7 8 9 10
None Mild Moderate Severe The most
imaginable
J. Circle the number to indicate how much your pain has interfered with your sleep in the past week.
0 1 2 3 4 5 6 7 8 9 10
None Mild Moderate Severe The most
imaginable
III. Current Medications
List ALL medicines and supplements you are currently taking for medical and pain problems (including
prescribed, over-the-counter, herbs, vitamins): (Write on the back of this sheet if necessary)
Name Pill strength Number of times taken per day Doctor who prescribed
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IV. History of Your Pain
A. When did your pain start?_____________________________________________________________
B. When did your pain become a problem? _________________________________________________
C. How many times have you gone to the emergency room for pain in the past year? _________________
D. What event or events led to your present pain:
accident other disease following an operation
cancer no obvious cause other ______________________
E. What do YOU think is the cause of your pain?
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VI. X-rays and Tests
Please list, in chronological order, all tests and x-rays performed to evaluate your pain:
Date Test Results
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VII. Previous Treatments
Indicate which of the following treatments you have tried for your pain problem:
anti-depressants acupuncture psychotherapy homeopathy
pain medications chiropractic biofeedback TENS
nerve blocks massage relaxation training exercise program
traction physical therapy hypnosis other (list) _______
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VIII. Previous Medications
List all previous pain medications you have taken for pain:
Name of medicine Dose Dates of use Helpful? Reason for stopping
__________________ _________ _____________ YES NO ____________________________________
__________________ _________ _____________ YES NO ____________________________________
__________________ _________ _____________ YES NO ____________________________________
__________________ _________ _____________ YES NO ____________________________________
IX. Past Medical Problems: Please indicate any other medical problems you have had.
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X. Surgeries
List all operations, hospitalizations, or injuries you have ever had.
Year Type of Surgery Hospital Doctor
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XI. Allergies
List all allergies to medications and the reaction you had to any medicine:
Medicine Reaction Medicine Reaction
________________________________________
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________________________________________
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XII. Review of Systems Please check if you now have or have had any of the following:
A. General
weight loss
poor appetite
severe fatigue/low energy
B. Head and Neck
headaches
visual changes
mouth problems
neck pain
TMJ problems
C. Cardiac
exercise limitations
chest pain
irregular heartbeat
heart murmurs
high or low blood pressure
circulation problems
ankle swelling
D. Pulmonary
shortness of breath
cough
asthma or bronchitis
lung disease
sleep apnea
snoring
E. Gastrointestinal
abdominal pain
nausea or vomiting
constipation
diarrhea
history of ulcers or heartburn
F. Genitourinary
frequent or hesitant urination
pain with urination
blood in urine
incontinence
G. Gynecologic
pregnant
sexual dysfunction
post-menopausal – Last
period:________
H. Neurologic
numbness
weakness
falling or loss of balance
stroke
seizures
memory loss
I. Hematological
anemia
easy bruising
bleeding disorder
taking blood thinners
J. Endocrine
Diabetes
thyroid problems
K. Musculoskeletal
arthritis - Type:___________
osteoporosis
muscle pain
muscle wasting
fractures
L. Infectious Diseases (circle answers)
measles, mumps, chicken pox
rheumatic fever
hepatitis Type A, B, C, other
HIV / AIDS
herpes (oral or genital)
shingles, post-herpetic neuralgia
Immunizations: flu, pneumonia
M. Skin
rash
nail changes
bumps/nodules
XIII. Psychological History
A. Describe your mood.
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B. Do you have problems with any of the following:
concentration anxiety appetite
motivation depression homicidal thoughts
sleep self-worth suicidal thoughts
C. Do you have a history of physical, mental, or sexual abuse? Yes _____ No _____
D. Are you currently in psychotherapy? Yes _____ No _____
E. If Yes, Name _______________________________: Degree M.D.____; Ph.D. ____; MFCC ____
Phone # (_______) _______________________________
F. If Yes, how often do you see the person in #E above: ________________________
XIV. Habits
A. Smoking: No___ ; Yes___: Number of Packs/Day_______
Quit ___ Number of years smoked _______
B. Alcohol Use: None ___ Occasional___ Daily ___ How much per week? ____________
C. Recreational Drugs: Current use ? Yes ______; No ______
D. Caffeinated Beverages: Number of Cups/Day__________
E. Clenching teeth: Yes _____ No _____ Grinding Teeth: Yes _____ No _____
F. Do you wear an intra oral appliance? Yes _____ No _____
G. Is anyone concerned about your use of alcohol, drugs, or medications? Yes _____ No _____
XV. Family History
Member Deceased or Living Age Medical Problems
1. Father ________________ ____ _______________________________
2. Mother ________________ ____ _______________________________
3. Siblings ________________ ____ _______________________________
________________ ____ _______________________________
________________ ____ _______________________________
4. Spouse ________________ ____ _______________________________
Where where you born? _______________________________________________
Are you adopted? Yes _____ No _____
XVI. Social History
A. Relationship Status
Single Separated
Partnered Divorced
Married Widowed
B. Highest level of education you have completed:
Less than high school College
High school Graduate
Vocational Other______________
C. Do you have children? List their ages: ____________________________________
For women: How many times have you been pregnant? ______________
D. With whom do you live? Name: ______________________________ Relationship: ______________
E. What is your current employment status?
Employed full time
Employed part time
Self Employed
Homemaker
Retired
Unemployed due to pain
Unemployed due to other
reasons: _______________
How long? _____________
Are you on disability? Yes___ No___
Date disability started:____________
Reason for disability:
______________________________
______________________________
F. Number of hours worked per week: __________ Are you happy with your job? ________________
Your current or most recent occupation __________________________________________________
XVII. Legal Information
Do you have any legal action pending related to this pain or any other health problem? Yes ___ No ___
If yes please list: Attorneys name ___________________________________________________________
Address _____________________________________________________________
Phone # _____________________________________________________________
XVIII. Healthcare Decisions (check boxes that apply)
Patient prefers to make own medical decisions
Medical decisions are made jointly between patient and family
Patient prefers family members to make the major medical decisions
Patient has Advanced Directives Copy of Directives given to CSMC
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Your signature Date
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Reviewed By: Date |
