Questionnaire Instructions

… Please take the time to carefully answer all sections and both sides of the patient questionnaire/Form.

… This questionnaire must be completed before you can be seen by a physician.

… If you do not completely fill out the questionnaire, your physician may elect to reschedule your appointment, until such time that the form has been completed.

… Do not wait until you come to your visit to complete the form.

… Put an ìxî next to anything that applies to your condition.

… Put an ì¯î if it does not apply, or you have never heard of it.

… If you do not know or are not sure, put an ì?î next to it.

… There should be no blank lines when finished.

… Do not forget to read the instructions on how to complete ìSection 2î. This is the single most important part of the entire document.

… Unless physically unable, the questionnaire should be completed by the patient himself (herself). If the patient cannot read and write, or is missing the arms, then a family member or a guardian should complete the questionnaire, prior to coming to the visit/appointment

NOTE: The rest of these instructions are provided as reference to each section.

Part I ñ History of Present illness: All of this information is necessary to provide a diagnosis. Not providing accurate or complete information may lead to the wrong conclusions.

Section 1. Onset and Duration: You must indicate either sudden or gradual. Exact dates are essential. In the case of gradual onset, or if you do not remember the exact date, give us your best estimate. Do not forget to calculate the duration of your symptoms. Indicate if this number is in days, months, or years, by circling the appropriate answer.

Section 2.

N

S

Location: This is the most important portion of the entire questionnaire/Form. Take the time to carefully and accurately draw your pain over the provided diagrams. Use a #2 pencil when shading the appropriate areas. Feel free to label areas of numbness (N), and/or areas where you have spasms (S). Sharp pains may be labeled with an ìxî. Different problems produce different pain patterns. See the following example:

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Section 3. Cause of Pain: Mark one of the alternatives, or if none applies, provide a brief explanation on how the pain started.

Section 4. Severity: Carefully indicate how bad your pain is, when at its best, at its worse, today, and most of the time. There should be a number, from 0 to 10, in each of the blanks on the right side column. ì0î means ìno painî. ì10î means the worse pain that you can even imagine. ì10î should be the equivalent of being eaten alive by a shark or having surgery without anesthesia. This section is important because it gives credibility to your ability to rate pain. For example, if you tell us that you currently have a ì10î /10 (read as ìten over tenî), and yet, you are sitting down comfortably, carrying a normal conversation, this will tell us that you have a tendency to exaggerate the amount of pain that you are in.

Section 5. Timing: Certain conditions give you pain in the mornings and others in the afternoon. Accurately answering this can help us further determine the cause of your pain.

Section 6. Aggravating Factors: Put an ìxî next to anything that applies, an ì¯î if it does not, and an ì?î if you do not know.

Section 7. Alleviating Factors: Same as above.

Section 8. Associated Problems: Same as above.

Section 9. Quality: Same as above.

Section 10. Previous Examinations or Tests: Put an ìxî next to all the tests that you have had done to evaluate this particular pain, put an ì¯î if you have not had it done, and an ì?î if you do not know. Remember, if you have never heard the term before, it is unlikely that you had it done.

Section 11. Previous Treatments: Put an ìxî next to all the treatments that you have had for this particular pain, put an ì¯î if you have not had it, and an ì?î if you do not know. Remember, if you have never heard the term before, it is unlikely that it has been used on you.

Section 12. Additional Information: Answer to questions the best you can.

Section 13. Physician Notes: Do not write anything in this section. This section is for official medical staff use only.

Part II ñ Review of Systems: This section is used to document those things in your medical history, which may influence the type of treatment and medications that we use.

Section 14. Cardiovascular History: Put an ìxî next to anything that applies, an ì¯î if it does not, and an ì?î if you do not know.

Section 15. Pulmonary or Respiratory History: Same as above.

Section 16. Neurological History: Same as above.

Section 17. Psychological-Psychiatric History: Same as above.

Section 18. Gastrointestinal History: Same as above.

Section 19. Genitourinary History: Same as above.

Section 20. Hematological History: Same as above.

Section 21. Endocrine History: Same as above.

Section 22. Rheumatologic History: Same as above.

Section 23. Musculoskeletal History: Same as above.

Section 24. Other Significant History: Put an ìxî next to anything that applies, an ì¯î if it does not, and an ì?î if you do not know. At the end, feel free to go back to this section and add anything that you feel is pertinent to your condition, but that we did not ask.

Section 25. Social History: Put an ìxî next to anything that applies, an ì¯î if it does not, and an ì?î if you do not know. If you have no children, under ìNumber of Childrenî write ì0î.

Section 26. Work History: Put an ìxî next to anything that applies, an ì¯î if it does not, and an ì?î if you do not know.

Section 27. Surgical History: Put an ìxî next to anything that applies, an ì¯î if it does not, and an ì?î if you do not know. In a separate paper, provide us with a list of your surgeries, date of surgery, surgeon, hospital and city where surgery was performed, and any complications that you might have had.

Section 28. Family History: Put an ìxî next to anything that applies, an ì¯î if it does not, and an ì?î if you do not know. Do not include yourself in this section. This is strictly for conditions that affect other members of your family. Names are not necessary, but provide relation to you (Example: ìFatherî, ìMotherî, etc.).

Section 29. Physicians involved in your care: Put an ìxî next to anything that applies, an ì¯î if it does not, and an ì?î if you do not know. In a separate paper, provide us with the name, address, and telephone number of all of your physicians (current and past).

Section 30. Physician Notes: Do not write anything in this section. This section is for official medical staff use only.

NOTE: We do understand that this is a long questionnaire, but it only has to be done once, and it provides us with information that is essential to the correct diagnosis and treatment of your condition. The proper completion of the document also tells us a great deal about your interest in getting better and helping us achieve that goal.Ý With time, we have learned that only patients with alternate motives, tent to avoid providing us with the required information.

PartÝ I ñ Pain History (History of Present illness)

Section 1 - Onset and Duration

ÝÝÝÝÝ Section 8 ñ Associated Problems ñ Which of these do you have?

___Sudden onset

How long have you had Pain? _____________________________ (Days, Months, Years)

___Color changes

___Numbness

___Gradual onset

___Constipation

___Personality changes

Date of onset: ____________

___Day-time Cramps

___Sadness

___Night-time Cramps

___Spasms

Section 2 ñ Location ñ Please shade all areas where you have pain

___Depression

___Suicidal Ideations

___Dizziness

___Sweating

___Erectile dysfunction

___Swelling

___Fatigue

___Temperature changes

___Impotence

___Tingling

___Inability to concentrate

___Vomiting

___Inability to control bladder

___Weakness

___Inability to control bowel

___Pain Wakes me up

___Nausea

___Pain does not let me sleep

ÝÝÝÝÝ Section 9 ñ Quality ñ Which of the following describes your pain?

___Aching

___Fearful

___Sharp

___Agonizing

___Feeling of constriction

___Shooting

___Annoying

___Feeling of Weight

___Sickening

___Burning

___Getting longer

___Splitting

___Constant

___Getting shorter

___Stabbing

___Intermittent

___Heavy

___Superficial

___Cramping

___Horrible

___Tender

___Cruel

___Hot

___Throbbing

___Deep

___Itching

___Tingling

___Disabling

___Lancinating

___Tiring

___Distressing

___Nagging

___Toothache-like

___Dreadful

___Pressure-like

___Uncomfortable

___Dull

___Pulsating

___Work-related

___Exhausting

___Punishing

Section 3 ñ Cause of your pain ñ What started your pain?

___Work-related accident or event

Date:________

ÝÝÝÝÝ Section 10 ñ Previous Examinations or Tests

___Is this under ìWorkers Compensationî?ÝÝ Yes_____ÝÝÝÝÝÝÝÝÝÝÝÝÝ NO_____

___Biopsy

___Endoscopy

___Nerve Conduction Test

___Motor vehicle accident

Date:________

___Bone Scan

___Epidurogram

___Neurological Evaluation

___Unknown

___Other (Briefly explain):

___CPT

___MRI Scan

___Neurosurgical Evaluation

___CT Scan

___Myelogram

___Orthopedic Evaluation

___CT- Myelogram

___Nerve Blocks

___Chiropractic Evaluation

Section 4 - Severity

___Discogram

___Spinal Taps

___Psychiatric Evaluation

___Getting Better

Please indicate using a scale from 0 to 10, how bad your pain is:

___EMG/PNCV

___X-rays

___Getting Worse

___No change since its onset

1) At its worse:______/10

ÝÝÝÝÝ Section 11 ñ Previous Treatments ñ Please draw a star (ð )next to those that helped.

2) At its best:______/10

3) Now:______/10

___Biofeedback

___Radiofrequency

4) Most of the time:______/10 (Average)

___Chiropractic manipulations

___Relaxation therapy

___Cryoanalgesia

___Spinal Cord Stimulator

Section 5 ñ Timing ñ When is your pain worse?

___Epidural steroid injections

___Steroid Treatments (by mouth)

___Not influenced by the time of the day.

___During activity or exercise

___Facet blocks

___Strengthening exercises

___Mornings

___After activity or exercise

___Hypnotherapy

___Stretching exercises

___Afternoons

___After immobility

___Morphine pump

___TENS

___Night

___Narcotic medications

___Traction

___Physical therapy

___Trigger point injections

Section 6 ñ Aggravating Factors ñ What makes your pain worse?

___Pool exercises

___Bending

___Motion

___Twisting

___Bowel Movements

___Nerve Blocks

___Walking

ÝÝÝÝÝ Section 12 ñ Additional information

___Climbing

___Sitting (prolonged?)

___Walking uphill

Ý1) Number of visits to the Emergency Room in the past 2 month: _____

___Eating

___Standing (prolonged?)

___Walking downhill

Ý2) Number of Physicians that you have seen for this problem: _______

___Intercourse (Sex)

___Squatting

___Working

3) Have you ever been seen by another pain management specialist or in another Pain Clinic?ÝÝÝÝÝ Yes____ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ NO____

___Kneeling

___Stooping

___Lifting

___Surgery made it worse

Ý4) Is there, or will there ever be any litigation related to your condition?

Yes_____ÝÝÝÝÝÝÝÝÝÝÝÝÝ

NO_____

Section 7 - Alleviating Factors ñ What makes your pain better?

Ý5) Are you considering pursuing disability?ÝÝÝÝÝ Yes____ÝÝÝÝÝÝÝÝÝÝÝÝÝ NO____

___Acupuncture

___Resting

___Walking

___Bending

___Sitting

Section 13 ñ Physician Notes

___Biofeedback

___Sleeping

___Stretching

___Standing

___Cold packs

___TENS

___Hot packs

___Using a Brace

___Hypnosis

___Relaxation Therapy

___Lying down

___Physical Therapy

Ý

___Medications

___Warm showers or baths

___Nerve Blocks

___ Chiropractic manipulations

Reviewing Doctorís Signature:

Part II - Review of Systems
ÝSection 14 ñ Cardiovascular History					Ý Section 25 ñ Social History
___Heart Trouble			___Heart Failure		___MarriedÝÝÝ ___SingleÝÝÝ ___DivorcedÝÝÝ ___WidowerÝÝÝ ___Separated
___Abnormal Heart Rhythm			___Congestive Heart Failure		___No ChildrenÝÝÝÝÝÝ Number of Children: ___________
___Daily Aspirin intake			___Heart Murmur		___Smoking: I have smoked as many as ___Packs of cigarette per day
___High Blood Pressure			___Heart Valve Problems			I started smoking when I was _____years old.
___Chest Pain			___Heart Catheterization		ÝÝÝÝÝÝ ___ I quit smoking ____ (years, months, days) ago.
___Heart AttackÝÝ Date:______			___Blood Thinners (Coumadin, Ticlid, Aspirin, etc.)		___Never smoked		___I have been told that I snore
___Heart Surgery					___Alcohol abuse		___Convicted of ìDriving Under the influenceî
___Pacemaker or defibrillator			___Need antibiotics prior to dental work		___Alcoholism		___Accused or convicted of any crimes
					___Drug Addiction
Ý Section 15 ñ Pulmonary or Respiratory History					___illegal drug use
___Lung Problems			___Smoker		Ý Section 26 ñ Work History
___Asthma			___Bronchitis		___Working (Part-time, Full-time)				___Retired
___Emphysema			___Sarcoidosis		___Type of work:___________________________________________
___Shortness of breath			___Exposure to Tuberculosis		___Disabled since________(Date), due to:_______________________
___I have been told that I snore			___Sleep apnea		___Out of work due to pain since__________(Date)
Ý Section 16 ñ Neurological History					___I quit going to work on my own.
___Seizure disorders			___Scoliosis (Crooked Spine)		___I was given a ìwork excuseî by my Doctor (indicate name below)
___Convulsions			___Incontinence (Urinary or Fecal)
___Epilepsy	Date of last attack: _______				Ý Section 27 ñ Surgical History
___Stroke	Residual deficits or weakness:				___Heart Surgery				___Neck Surgery
___Peripheral Neuropathy			___Tethered Cord Syndrome		___Lung Surgery				___Hip Surgery
___Spina Bifida					___Back Surgery				___Knee Surgery
Ý Section 17 ñ Psychological-Psychiatric History					___Other:
___Psychiatric Disorder			___Suicidal Ideations
___Anxiety			___Attempted Suicide		Ý Section 28 ñ Family History ñ Please indicate affected family member
___Depression			___History of having been abused		___Alcoholism
___Panic Attacks			___Insomnia		___Chronic Pain
					___Diabetes
Ý Section 18 ñ Gastrointestinal History					___Drug Addiction
___Ulcers				___Hepatitis	___High Blood Pressure
___Hiatal Hernia				___Cirrhosis	___Cancer(indicate what kind?)
___Reflux or Heartburn				___Pancreatitis
___Irritable Bowel Syndrome (IBS)				___Constipation	Ý Section 29 ñ Physicians involved in your care (Name & Telephone)
					Specialty			Name		Telephone No.
Ý Section 19 ñ Genitourinary History					___Primary Care Physician:
___Kidney disease		___Blood in urine			ÝÝÝÝÝ (Family Doctor or Internist)
___Renal Failure (Dialysis?)		___Recurrent urinary tract infections			___Neurosurgeon:
___Kidney Stones					___Orthopedic Surgeon:
					___Psychologist:
Ý Section 20 ñ Hematological History					___Psychiatrist:
___Anemia		___Sickle Cell Disease or Trait			___Other:
___Bruise easily		___Coagulation Disorder
___Easy Bleeder		___Low platelet count			I hereby certify that I have personally filled out this Form, both, Part I and Part II, to the best of my abilities. I also recognize that this document is essential for the correct diagnosis and treatment of my condition. I also understand that if any of this information is found to have been omitted or manipulated, this alone would be grounds for my dismissal from this program.
___Hemophilia
Ý Section 21 ñ Endocrine History
___Diabetes (IDDM, NIDDM)
___Thyroid Disease (Low, High)
Ý Section 22 ñ Rheumatologic History					Name: ___________________________________________________
___Lupus			___Fibromyalgia
___Osteoarthritis			___Myositis / Polymyositis		Patientís Signature:
___Rheumatoid arthritis			___Chronic Fatigue Syndrome		Section 30 ñ Physician Notes and
					___Confirmed that patient has seen the welcome video.
Ý Section 23 ñ Musculoskeletal History					___Confirmed that patient received and read ìNew Patient Information Packageî.
___Myasthenia Gravis			___Multiple Sclerosis
___Muscular Dystrophy			___Malignant Hyperthermia		___Confirmed that patient has a Primary Care Physician.
Ý Section 24 ñ Other Significant History
___Weight loss			___Problems with Anesthesia
___Exposure to AIDS
___Cancer: (What kind/location?) _____________________________
___Other:
					Reviewing Physicianís Signature: