6) What is the intensity of your pain on a of 1-10 (0=no pain, 10=worse pain ever) At best: ____________________________ At worst: ____________________________ On Average: _______________________ 7) Check any of the following that describe the quality of your pain: [ ] Dull [ ] Sharp [ ] Burning [ ] Shooting [ ] Aching [ ] Pinpoint 8) Check any treatments you have tried in the past to treat your pain: Physical Therapy Chiropractor Massage Ice/ Heat □ □ □ □ □TENs □ 9) Is your pain associated with any of the following? Weakness Numbness Tingling Skin color/temperature changes ∎ ∎ ∎ Yes Yes Yes Yes ○ ○ ○ ○ No No No No ○ ○ ○ ○ Bladder or bowel problems Skin sensitive to light touch Skin sensitive to heat/cold ∎ ∎ Yes Yes Yes ○ ○ ○ No No No ○ ○ ○ 10) Check which factors make your pain better: Sitting Standing Walking Bending forward □ □ □ □ Driving Coughing/Sneezing Lying down □ □ □ 11) Check which factors make your pain worse: Sitting Standing Walking Bending forward down □ □ □ □ □ Driving Coughing/Sneezing Leaning back □ □ □ 12) List other Doctors who have treated you for this: 13) List any that have been performed: (i.e. MRI, CAT scan, Myelogram, EEG, etc.) and list the year and facility where the test was done: 14) Have you previously had any injections/epidurals for your pain? If yes, when and where? 15) Have you been treated by other pain specialists/clinics in the past? If yes, when and where?
6) What is the intensity of your pain on a of 1-10 (0=no pain, 10=worse pain ever) At best: ____________________________ At worst: ____________________________ On Average: _______________________ 7) Check any of the following that describe the quality of your pain: [ ] Dull [ ] Sharp [ ] Burning [ ] Shooting [ ] Aching [ ] Pinpoint 8) Check any treatments you have tried in the past to treat your pain: □ Physical Therapy □ Chiropractor □ Massage □ Ice/ Heat □TENs □ 9) Is your pain associated with any of the following? Weakness ∎ Numbness ∎ Tingling ∎ Skin color/temperature changes ○ Yes ○ Yes ○ Yes ○ Yes ○ No ○ No ○ No ○ No Bladder or bowel problems ∎ Skin sensitive to light touch ∎ Skin sensitive to heat/cold ○ Yes ○ Yes ○ Yes ○ No ○ No ○ No 10) Check which factors make your pain better: □ Sitting □ Standing □ Walking □ Bending forward □ Driving □ Coughing/Sneezing □ Lying down 11) Check which factors make your pain worse: □ Sitting □ Standing □ Walking □ Bending forward □ down □ Driving □ Coughing/Sneezing □ Leaning back 12) List other Doctors who have treated you for this: 13) List any that have been performed: (i.e. MRI, CAT scan, Myelogram, EEG, etc.) and list the year and facility where the test was done: 14) Have you previously had any injections/epidurals for your pain? If yes, when and where? 15) Have you been treated by other pain specialists/clinics in the past? If yes, when and where?
new-patient-packet.docx