Request First Appointment
Home
About Us
Areas We Serve
Contact Us / Directions
Staff & Doctors
Services
links
RSS
Pain Management
Pain and Debilitating Conditions
Pharmacologic Pain Management
Interventional Pain Management
Pain Rehabilitation
Alternative Pain Management
Frequently Asked Questions
Request An Appointment
/pdf/newpatientform.pdf
Pain Condition and Procedure Videos


Questionnaire

Patient's First Name
Patient's Last Name
Email
Date of Birth
Sex
Height ft.  in.
Weight lbs.
Primary care physician
Primary care physician phone
Referring physician
Referring physician phone
Other physicians consulted
Other physicians consulted phone
When did your pain start?
How did your pain start?
:
Describe the Problem
Briefly List
Treatments tried
Injections tried
Medications tried
Physical therapy tried
Have you had any previous...
When
facility name
When
facility name
When
facility name
When
facility name

Describe where your pain is on your body

Please indicate on a scale of 0-10 what level your pain is,
0 = no pain, 10 = unbearable pain
PRESENT PAIN
USUAL PAIN
LEAST SEVERE PAIN
WORST PAIN

In the last 2-3 weeks, how often has your pain occured?

What does your pain feel like? (check all that apply)
Other, please describe:

What increases your pain? (check all that apply)
Other, please describe:

What decreases your pain? (check all that apply)
Other, please describe:
   
Do you have any numbness?
Do you have any weakness?
Does it keep you from falling asleep?
Do you have any changes in your bowel/bladder?
How often do you use the emergency room for pain control?
 
Past and Present Medical Problems
High Blood Pressure
Chest Pain
Heart Attack
Diabetes
Stroke
Epilepsy
Emphysema
Asthma
Stomach Ulcers
Hepatitis
Cancer
Arthritis
Headaches
Shingles
Lyme
Hypothyroid
Other
 
Please list all surgeries you have had:
Date Surgery Physician
     
Do you use anticoagulants/blood thinner?
(select which one)

Other:
   
Allergies
 
Social History
Do you smoke?
If so, how many packs per day?
If stopped, when?
Do you consume alcohol?
How much?
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Do you consume caffeinated beverages?
How much?
Do you take prescription pain medications?
If yes, do you take more than the prescribed amount?
Have you ever been treated for substance abuse?
If so, describe details?
Are you married?
Do you live alone?
Are you a care giver to anyone?
Is there someone at home who can help you with activities of daily living?
Are you working?
Occupation and description of job?
If not working
Date last worked
Is your pain keeping you from working?
Who released you from work?
When are you scheduled to return?
Are you on Worker's Comp?
Date started
Are you on Disability?
Date started
What type of Disability do you have?
What is the medical diagnosis for this disability?
 
Family History
Is your father alive?
Cause of death
What health problems does your father have?
Is your mother alive?
Cause of death
What health problems does your mother have?
Do you have any blood relatives/children/siblings with significant medical problems?
Explain
 
Behavioral Health
How has the pain affected your personality? Check all that apply.
What stress has the pain caused you at home/work?
Are you depressed now?
Do you have thoughts of suicide?
Do you want to see a behavioral health specialist to help you deal with the pain?
Have you ever seen a counselor, psychologist, or psychiatrist?
Please include their name, date last seen, and office number.
What type of behavioral health treatment have you tried?
Other:
 
Review of Systems
Constitutional
Eyes
ENT/Mouth
Cardiovascular
Pulmonary
Gastrointestinal
Urological
Musculoskeletal
Endocrine
Skin
Blood
Immune compromise
Neurological
Psychological
 
For men only
do you have problems with erections?
 
For women only
could you be pregnant now?
date of last menstrual period

Be sure that you have entered information in all fields before clicking Submit.

 
Leave this blank:
NJ Monthly Top Doctor 2013

Sitemap | Privacy Policy & Terms of Use

Home | About Us | Areas We Serve | Contact Us/Directions | Staff and Doctors | Services | Latest News | Links
Pain and Debilitating Conditions | Pharmacologic Pain Management | Interventional Pain Management
Pain Rehabilitation | Alternative Pain Management | FAQs
Request an Appointment | New Patient Information Form | Questionnaire Form | Pain Condition & Procedure Videos

Website Design by DDA Medical

Request an Appointment New Patient Information Form Questionnaire Form