Comprehensive Pain Care, P.C.
Patient Information
Name: ________________________________________ Date: __________________
Date of Birth: ______________ Age: _______________ Sex: ___ Male ___ Female
Past Medical History
Have you ever been hospitalized? __ Yes ___ No If yes, what for?_________________
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Which of the following conditions are you currently being treated or have been treated for in the
past (please check):
___Heart disease / Murmur / Angina ___Shortness of breathe
___Eye disorder / Glaucoma ___Diabetes
___High cholesterol ___Asthma
___Seizures ___Kidney / Bladder problems
___High blood pressure ___Lung problems / cough
___Stroke ___Liver problems / Hepatitis
___Low blood pressure ___Sinus problems
___Headaches / Migraines ___Arthritis
___Heartburn (reflux) ___Seasonal allergies
___Neurological problems ___Cancer
___Anemia or blood/bleeding problems ___Depression / Anxiety
___Ulcers/colitis ___Psychiatric care
___Thyroid problems
Please describe any current or past medical treatment/problems not listed above:
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Please list your past surgeries
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Medication or other Allergies ___Yes ___No
Please list any allergies: ______________________________________________________
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List your current Medications:
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Do you currently smoke or chew tobacco? ___Yes ___No
If no, have you in the past? ___Yes ___No How many packs per day? ____________
How much alcohol, beer, or wine do you drink in a week?______________________________
If none, have you drank in the past? ___Yes ___No If yes, How much per week? _______
Do you have a current or past history of drug or alcohol abuse? ___Yes ___No
If yes, explain:________________________________________________________________
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Has any member of your family (including children and parents) had any history of drug or alcohol
abuse o raddiction? ___Yes ___No If yes, explain:___________________________________
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Current Physicians (include name and phone number and/or office address):
Primary Care Physician: _______________________________________________________
Psychiatrist: _________________________________________________________________
Clinical Psychologist and/or counselor:____________________________________________
Specialty physicians (Ortho, Neuro, Cardiac, etc.): ___________________________________
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Domestic Situation: Circle one: Single Married Widowed Divorced
With whom do you live?_________________________________________________________
Are there any alcohol or drug abuse issues in the household? ___Yes ___No
If yes, explain:_________________________________________________________________
Current or last job:_____________________ How many years employed?________________
Are you presently involved in a lawsuit? ___Yes ___No
If yes, explain:_________________________________________________________________
When and how did your pain problem start?_________________________________________
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As far as you know, what is the cause of your pain (i.e. the diagnosis)? ___________________
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What tests and studies have been done and when were the done (X-rays, MRI, etc.)? ________
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What doctors have you seen for this problem in the past? (Do not list current physicians listed
previously.) When did you see them? What did they do? (For example: Doctor did physical exam,
ordered tests, prescribed medication):_____________________________________________
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Circle the words that describe your pain:
Arching Throbbing Shooting Stabbing Gnawing Intermittent
Sharp Tender Burning Exhausting Tiring Continuous
Penetrating Nagging Numb Miserable Unbearable
Rate your pain using a scale where 0 = no pain and 10 = the worst pain that you can possibly imagine:
Your pain at its worst during the last month: _____
Your pain at its least during the last month: ______
Your pain on average during the last month: _____
Your pain as it is right now: _____
What sort of things make this pain feel better (for example: heat, rest, medicine)? ___________
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What sort of things make this pain feel worse (for example: walking, standing, lifting)? ________
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Which of the following statements best reflects the effect of my current pain medications (check one):
_____My pain medication does not help at all.
_____My pain medication provides some relief but not enough to be considered meaningful.
_____My pain medication helps and definitely improves my quality of life.
What things do you want or need to do that your pain interferes with significantly?___________
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To my knowledge all the information I have furnished on this form is complete, true and accurate.
Patient (or legal guardian) Signature ____________________________________________
Date ________________
