"Initial Pain Evaluation Form - Chippewa Valley Orthopedics & Sports Medicine"

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INITIAL PAIN EVALUATION FORM
Note: This is a confidential record and will be kept in your doctor’s office. Information contained here will not be releas ed to anyone without your
authorization to do so.
TODAY’S DATE
____/____/____
FAMILY DOCTOR
NAME_____________________________
DATE OF BIRTH ____ /____ /____
SOCIAL SECURITY #____________________
CHIEF COMPLAINT
What is the main reason for your visit today? (Describe your problem in detail)
-
Were you referred to us by another health care professional? (If yes please state name)_________________________
HPI:
Height: _______________
Weight: ______________
My current Problem is the result of a (check all that apply):
Car Accident
 Work Injury
 Legal Case
 Other _____________
When did the problem first start? ______________________________________________________
Date, if accident or work injury ________Has a workers’ compensation claim been filed?  Yes  No
Have you seen other physicians for this problem?
Yes
No
If so, who? __________________________
What treatments have you had for this problem?
Location of the problem:
(check all that apply)
 Physical Therapy
(check all that apply)
 Low Back
 Injections
 Buttock (Right Left Both)
 Chiropractic
 Leg (Right Left Both)
 Surgery
 Neck
 TENS
 Arm (Right Left Both)
Severity:
 Mild  Moderate  Severe
What activities make it better?
What activities make it worse?
 Rest
 Walking
 Stretching
 Sitting
 Ice
 Standing
 Heat
 Lying Down
 Riding / Driving
 Coughing / Sneezing
CSC INITIAL PAIN EVALUATION FORM 100510.doc
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INITIAL PAIN EVALUATION FORM
Note: This is a confidential record and will be kept in your doctor’s office. Information contained here will not be releas ed to anyone without your
authorization to do so.
TODAY’S DATE
____/____/____
FAMILY DOCTOR
NAME_____________________________
DATE OF BIRTH ____ /____ /____
SOCIAL SECURITY #____________________
CHIEF COMPLAINT
What is the main reason for your visit today? (Describe your problem in detail)
-
Were you referred to us by another health care professional? (If yes please state name)_________________________
HPI:
Height: _______________
Weight: ______________
My current Problem is the result of a (check all that apply):
Car Accident
 Work Injury
 Legal Case
 Other _____________
When did the problem first start? ______________________________________________________
Date, if accident or work injury ________Has a workers’ compensation claim been filed?  Yes  No
Have you seen other physicians for this problem?
Yes
No
If so, who? __________________________
What treatments have you had for this problem?
Location of the problem:
(check all that apply)
 Physical Therapy
(check all that apply)
 Low Back
 Injections
 Buttock (Right Left Both)
 Chiropractic
 Leg (Right Left Both)
 Surgery
 Neck
 TENS
 Arm (Right Left Both)
Severity:
 Mild  Moderate  Severe
What activities make it better?
What activities make it worse?
 Rest
 Walking
 Stretching
 Sitting
 Ice
 Standing
 Heat
 Lying Down
 Riding / Driving
 Coughing / Sneezing
CSC INITIAL PAIN EVALUATION FORM 100510.doc
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Please draw area of pain. If the pain radiates, describe this as well:
Right
Left
Left
Right
FRONT
BACK
Please mark all that apply to you now or that you have had in the past!
Eyes
Y N Genitourinary
Y N Endocrine
Y N
Glaucoma
Can’t control urine
Diabetes
Difficulty urinating
HENT
Y N
Psychiatric
Y N
Integumentary
Y N
Wearing hearing aide
Anxiety
Skin Cancer
Depression
Cardiovascular
Y N
Neurological
Y N Hematological
Y N
Chest pain/angina
Leg pain while walking
Sciatica
Bleeding Tendencies
Pacemaker
Arm Numbness/ Tingling
DVT
Leg Numbness/ Tingling
Allergic
Respiratory
Y N
Y N
Musculoskeletal
Y N
Asthma/Emphysema
Food allergies
Neck Pain
Medication allergies
Gastrointestinal
Y N
Arm Pain
Iodine allergy
Blood in vomit
Back Pain
Female
Y N
Colon cancer
Leg/ Foot Pain
Are you pregnant?
Unsure?
PAST MEDICAL HISTORY:
List all chronic illnesses/conditions:
(Example: diabetes, heart disease, high blood pressure, etc.)
___________________
____________________ _____________________
___________________
____________________ _____________________
___________________
____________________ _____________________
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List any past surgeries
Surgery
Approximate Date
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Are you on any medications?
Y
N
(If yes, list all or provide a list)
_________________
___________________
______________________
_________________
___________________
______________________
_________________
___________________
______________________
___________________
_____________________
________________________
Do you have any medication allergies?
Yes  No (If yes, list all or provide a list)
_________________
___________________
______________________
_________________
___________________
______________________
_________________
___________________
______________________
SOCIAL HISTORY:
Do you smoke?
Do you drink alcohol?
Yes  No
Yes
 No
If yes, how much? _______________
If yes, how much? _________________
Occupation/Employer: ____________________________________________________
Have you had any complications with bleeding?
Yes  No
Do you take a blood thinner, such as Coumadin, Plavix, Heparin, Aspirin, etc?
If so, what? _______________
Family History:
Serious Health Problems / Important
Notes:
Mother
If deceased, at what age? ______
Father
If deceased, at what age? ______
The information given in the Patient History form is accurate to the best of my knowledge.
Signature________________________________________
Date __________________
CSC INITIAL PAIN EVALUATION FORM 100510.doc
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