name today`s date - Sparrow Health System

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Please fill out BOTH SIDES of this form as completely as possible.
This information will determine how we treat your pain problem.
Name
Today’s
date
Date of birth
Primary care
physician
Age
Referring
physician
Medical
Pain History 1
THIS
COLUMN
FOR OFFICE
STAFF USE
ONLY. ↓
WHERE is your pain? Color the areas on this diagram where your pain has been for the last 2-3 weeks:
RED = Excruciating pain
GREEN = Moderate pain
BLUE = Severe pain
YELLOW = Mild pain
WHEN did your pain start?
CC & HPI
timing 1/4
duration 2/4
location 3/4
quality 4/4
context 5/4
modifying factors
6/4
severity 7/4
sleep
In the last 2-3 weeks, WHEN
does your pain occur?
 intermittent (on/off)
 8-16 hrs/day
 less than 8 hrs/day
 constant
HOW did your pain start?
 auto accident
 work related
 after surgery
 fall (not at work)
 other, describe:
WHAT does your pain feel
like? (check all that apply)
 burning
 mild
 sharp
 moderate
 dull
 severe
 stabbing
 aching
 cramping
 other, describe:
What has been used to TREAT your pain? (check all that apply)
 medications  individual psychotherapy  other Pain Center
 biofeedback  group psychotherapy
 physical therapy
 injections
 relaxation training
 occupational therapy
 treatments in emergency room (ER) - how many times have
you been to the ER for pain control over the last 3 months? ______
 other, describe:
reviewed by
What DECREASES your pain?
 sitting
 bending
 standing
 lying flat
 walking
 other, describe:
(check all that apply)
 heat
 relaxation exercises
 cold
 rest
 not working
Copyright  2010 Mermaid Medical ALL RIGHTS RESERVED. v0329
 medications
 injections
 physical therapy
date
Medical Pain History 1
Please fill out this form as completely as possible.
Med Pain Hx 2
What INCREASES your pain? (check all that apply)
 sitting
 going up or down stairs
 driving a vehicle
 standing
 bending or transferring positions
 sports, physical recreation, crafts, or hobbies
 walking
 employment or working
 self-care (bathing, dressing, toileting, etc.)
 lifting, carrying, housework, or yard work (laundry, meal preparation, etc.)
 other,
describe:
THIS
COLUMN
FOR OFFICE
STAFF USE
ONLY. ↓
HPI (cont'd)
CARF
Does your pain keep you from falling asleep at night?  yes  no
Does your pain awaken you at night?  yes  no
What is your goal for treatment at the Pain Center?
(For example: What are the activities you would like to do if the pain was better controlled?)
Do you have any other comments about your pain, not already noted here?
Past Medical History - What are your past or current medical problems? (check all that apply)
 tumor or cancer
 colitis
 heart disease
 neurological disease
 pancreatitis
 rheumatic fever
 seizures
 bladder or kidney disease
 high blood pressure
 stroke
 arthritis
 lung disease
 tension headache
 diabetes
 bronchitis or pneumonia
 migraine headache
 thyroid or other endocrine
 asthma
disorder
 drug addiction or alcoholism
 liver or gall bladder problem
 anemia or blood disease
 chemical dependency treatment
 hepatitis

bleeding
disorder
 mental or nervous disorder
 peptic ulcer disease
 other medical or pain problems not previously noted, describe:
PMH 1/3
PSH 1/3
Past Surgical History - List ALL surgery & dates
(month/year):
meds 2/3
allergies 2/3
reviewed by
Do you use anticoagulants (such as heparin, coumadin, Fragmin,
Lovenox, enoxaparin, Normiflo, ardeparin, Orgaran, danaparoid)?  yes  no
(If yes, please include all anticoagulants on your medication list on the next page.)
Do you use over-the-counter medications?  yes  no
(If yes, please include all over-the-counter medications on your medication list on the next page.)
Do you use recreational drugs or medications which were prescribed for someone else?  yes  no
(If yes, please include all these medications on your medication list on the next page.)
Copyright  2010
Mermaid Medical
ALL RIGHTS RESERVED.
v0329
Name
date
DOB
Medical
Pain History 2
This list will be verified & updated every time you visit
the Pain Center. Please write legibly.
Name
Medication
Reconciliation 1
Med Pain Hx 3
Date
of
Birth
MEDICATIONS - Please list all your current prescribed and over-the-counter medications:
COLUMN 1
START YOUR
LIST HERE
medication - dose - frequency
COLUMN
2
continue your list
here from column 1
medication - dose - frequency
Copyright  2010 Mermaid Medical ALL RIGHTS RESERVED. v0329
COLUMN
3
continue your list
here from column 2
medication - dose - frequency
Medication Reconciliation 1 - Med Pain Hx 3
Please fill out the top part (ALLERGIES) of this page.
Medication Reconciliation 2 - Med Pain Hx 4
Allergies or medication problems: Please list all the medications you are allergic to and/or have had problems
tolerating. Briefly list the specific allergy or problem which occurred.
medication
allergy or problem
medication
allergy or problem
THIS SECTION FOR PAIN CENTER STAFF COMPLETION ONLY:
Date:
Med review by:
Date:
Med review by:
Date:
Med review by:
Date:
Med review by:
Date:
Med review by:
Date:
Med review by:
Date:
Med review by:
Date:
Med review by:
Date:
Med review by:
Date:
Med review by:
Copyright  2010
Mermaid Medical
ALL RIGHTS RESERVED.
v0329
Name
I reviewed my medication list on the
opposite side. I have been
informed to provide this list to my
next healthcare provider.
I reviewed my medication list on the
opposite side. I have been
informed to provide this list to my
next healthcare provider.
I reviewed my medication list on the
opposite side. I have been
informed to provide this list to my
next healthcare provider.
I reviewed my medication list on the
opposite side. I have been
informed to provide this list to my
next healthcare provider.
I reviewed my medication list on the
opposite side. I have been
informed to provide this list to my
next healthcare provider.
I reviewed my medication list on the
opposite side. I have been
informed to provide this list to my
next healthcare provider.
I reviewed my medication list on the
opposite side. I have been
informed to provide this list to my
next healthcare provider.
I reviewed my medication list on the
opposite side. I have been
informed to provide this list to my
next healthcare provider.
I reviewed my medication list on the
opposite side. I have been
informed to provide this list to my
next healthcare provider.
I reviewed my medication list on the
opposite side. I have been
informed to provide this list to my
next healthcare provider.
Patient signature:
Patient signature:
Patient signature:
Patient signature:
Patient signature:
Patient signature:
Patient signature:
Patient signature:
Patient signature:
Patient signature:
DOB
Medication
Reconciliation 2
Med Pain Hx 4
Please fill out BOTH SIDES of this form as completely as possible.
This information will determine how we treat your pain problem.
Review of systems constitutional
1/10
weight loss
fatigue
chills/fever
decreased appetite
eyes
 no
 no
 no
 no
 yes
 yes
 yes
 yes
 yes
 no
 no
 no
 no
 no
 yes
 yes
 yes
 yes
 yes
 yes
 yes
 yes
 no
 no
 no
 no
 no
 no
 no
 no
 yes
 yes
 yes
 yes
 no
 no
 no
 no
3/10
earache
ear discharge
hearing loss
ringing of the ears
ear infection
post-nasal drip
sore throat
bleeding gums
cardiovascular
4/10
chest pain
angina
palpitations
heart murmur
short of breath with
activity or at rest
respiratory
 yes  no
5/10
chronic cough
 yes  no
wheezing
 yes  no
short of breath at rest
 yes  no
If you smoke, how much do
you smoke?
If you drink beverages with
alcohol, how much do you
consume?
Has anyone complained about
your drinking?  yes  no
If yes, who complained?
If you drink beverages with
caffeine, how much do you
consume?
Copyright  2010
Mermaid Medical
ALL RIGHTS RESERVED.
v0329
Please check  yes or  no for each item:
gastrointestinal
 yes
 yes
 yes
 yes
2/10
eye discharge
glasses or contacts
excess tearing
eye pain
vision changes
ENT
Do you have?
Name
6/10
heartburn
peptic ulcers
nausea
vomiting
diarrhea
constipation
laxative use
jaundice
loss of bowel control
genitourinary
skin
 yes
 yes
 yes
 yes
 yes
 yes
 yes
 yes
 yes
 no
 no
 no
 no
 no
 no
 no
 no
 no
7/10
 yes  no
painful urination
 yes  no
urinary retention
 yes  no
urinary dribbling
 yes  no
loss of urinary control
 yes  no
8/10
joint pain
joint swelling
joint stiffness
muscle pain
muscle swelling
neurological
numbness
tingling
tremor
fainting
headaches
weakness
dizziness
endocrine
 yes  no
 yes  no
 yes  no
11/10
hot flashes
hair loss
always hot
always cold
always thirsty
 yes
 yes
 yes
 yes
 yes
hematologic - lymphatic
frequent urination
 yes  no
urinary tract infections
musculoskeletal
10/10
skin itching
skin rash
skin infection
 yes
 yes
 yes
 yes
 yes
 no
 no
 no
 no
 no
 yes
 yes
 yes
 yes
 yes
 yes
 yes
 no
 no
 no
 no
 no
 no
 no
9/10
Is your father alive?  yes  no
What health problems does your
father have? (If deceased, cause
of death?)
Is your mother alive?  yes  no
What health problems does your
mother have? (If deceased,
cause of death?)
easy bruising
easy bleeding
anemia
swollen nodes
allergic - immunologic
AIDS
steroid use
frequent infections
allergies
hives
psychiatric
Medical
Pain History 5
THIS
COLUMN
FOR OFFICE
STAFF USE
ONLY. ↓
ROS 10/14
 no
 no
 no
 no
 no
12/10
 yes
 yes
 yes
 yes
 no
 no
 no
 no
13/10
 yes
 yes
 yes
 yes
 yes
 no
 no
 no
 no
 no
 yes
 yes
 yes
 yes
 no
 no
 no
 no
14/10
anxiety
depression
mood swings
nightmares
FOR MEN ONLY
Do you have problems with
 yes  no
erections?
FOR WOMEN ONLY
Could you be pregnant now?
 yes  no
Marital status: Are you…?
 single
 married
 divorced
 widowed
Do you have children or other
dependents at home?
 yes  no If yes, please
list children’s ages, or
describe other dependents:
PFSH 3/3
reviewed by
date
DOB
Medical
Pain History 5
Please fill out this form as completely as possible.
Med Pain Hx 6
Current employer:
How many years
Occupation
have you worked
(brief job description
for this employer?
or type of work activity):
Are you working?  yes  no
If not working, when
If not working, is pain
did you last work?
preventing you from working?
If not working, when will
If not working, would
you like to return to work?
your off work slip expire?
If not working, who
took you off work?
Are you on disability?  yes  no
If yes, when did
If yes, what was the medical
your disability start?
diagnosis for your disability?
 other, describe:
If yes, which type of
 short term disability
disability do you have?  long term disability
(check all that apply)
 social security disability
Are you on Workers Compensation (WC)?  yes  no
If yes, when did your
Is your WC claim in dispute?
WC start?
If you are involved in a lawsuit(s), who is the lawsuit against? (check all that apply)
 other, describe:
 lawsuit regarding a disability claim
 lawsuit regarding an auto accident
 lawsuit with Workers Compensation
THIS
COLUMN
FOR OFFICE
STAFF USE
ONLY. ↓
 yes  no
work 3/3
WC
disability
litigation
 yes  no
 yes  no
diagnostics
Diagnostics - What diagnostic studies, such as xrays, CT scans, MRI’s, myelograms, EMG's
(electromyogram), or bone scans have been done within the last 5 years? List below, including type of
study, date completed, which part of the body was studied, and the hospital or office where the study
was performed. For example: MRI - 2001 - low back - Sparrow
diagnostic test - date - part of body - where
diagnostic test - date - part of body - where
Physicians, psychologists, or healthcare professionals involved in your care - List all physicians
and mental health professionals you have consulted (including those for non-pain complaints):
name - date last seen - office phone #
name - date last seen - office phone #
physicians
psychologists
other providers
reviewed by
date
Copyright  2010
Mermaid Medical
ALL RIGHTS RESERVED.
v0329
Name
DOB
Medical
Pain History 6
Please fill out BOTH SIDES of this form as completely as possible.
This information will determine how we treat your pain problem.
Name
Date
of
birth
Psychological
Pain History 1
Today’s
date
How has pain affected your personality? (check all that apply NOW)
 suicidal
 moody
 mildly upset
 discouraged
 irritable
 moderately upset
 unhappy
 mildly depressed
 severely upset
 moderately depressed  desperate
 no effect
 mildly withdrawn
 severely depressed
 disagreeable
 moderately
 uncooperative
 incapacitated
withdrawn
 complaining
 panicked
 severely
withdrawn
 tired
 dull
 bitter
 anxious
 frustrated
THIS COLUMN
FOR OFFICE
STAFF USE
ONLY. ↓
PSYCH
 other,
describe:
Since the pain, what are you concerned about? (check all that apply NOW)
 unidentified medical
 loss of recreational activities  change in family interaction
problems
 ability to continue or go
 change in sexual desire,
back to work
 poor sleep
interest or ability
 lack of interest in getting
 memory difficulties
 the pain lasting forever
together with people
 daytime fatigue
 concentration difficulties
 other,
describe:
What stress has
the pain caused
you at home?
What stress has
the pain caused
you at work?
What stresses
were you under
before the pain?
Are you
depressed
now?
 yes
 no
Have you ever been
depressed before
in your life?
Describe your mood
when you have
severe pain:
Describe how you
cope with the pain:
 yes
 no
Have you ever
attempted
suicide?
 yes
 no
reviewed by
date
Explain in your own
words why you
have the pain:
Copyright  2010 Mermaid Medical ALL RIGHTS RESERVED. v0329
Psychological Pain History 1
Please fill out this form as completely as possible.
Do you currently use alcohol for controlling pain?
Have you ever
been in
treatment for
abuse of alcohol,
cocaine, crack,
marijuana, or
other drugs?
 yes  no
Have you ever
been in legal
trouble because
of alcohol,
cocaine, crack,
marijuana, or
other drugs?
 yes  no
Psych Pain Hx 2
 yes  no
THIS COLUMN
FOR OFFICE
STAFF USE
ONLY. ↓
If yes, please describe:
PSYCH
If yes, please describe:
Describe yourself.
What kind of
person are you?
What is most
important in
your life?
Do you want to see a pain psychologist to help you deal with the pain?
 yes  no
Have you ever seen a counselor, psychologist, or psychiatrist at any time in your life?
 yes  no
If yes, please list all mental health professionals (psychiatrists, psychologists, social workers) you
have seen:
name - date last seen - office phone #
name - date last seen - office phone #
In addition to
decreased pain,
what do you
hope to get from
treatment at the
Pain Center?
Copyright  2010
Mermaid Medical
ALL RIGHTS RESERVED.
v0329
psychologists, other
mental health
professionals
reviewed by
date
Name
DOB
Psychological
Pain History 2
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