INTERVENTIONAL PAIN TREATMENT CENTER
FORT WALTON BEACH, FLORIDA
(850) 862-2912
1. Name Last: ________________________ First: _____________________ MI: _____
Date of Birth ___________
2. Age: ______ Height: _________ Weight: __________ Social Security #:
______________ Male / Female
3. Who referred you to us? _________________________________________________________
3a. Who is your primary care physician?_______________________________________________
4. Home Address and Phone #:______________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
5. Circle your pain: CONSTANT
INTERMITTENT DULL SHARP THROBBING NUMBING
ACHING SHOOTING BURNING TINGLING CRAMPING
5b. If 10 is the worst pain and 0 is no pain, circle your pain:
0 1 2 3 4 5 6
7 8 9 10
5c. Please mark the areas of your pain here:
6. When did you first start having pain? __________________________________________________
7. What caused your pain to begin? _____________________________________________________
8. Have you had this pain before? YES / NO When? ______________
Please explain: ________________________________________________________________________________
__________________________________________________________________________
_____________________________________________________________________________
10. Circle what makes the pain worse: WEATHER CHANGES, PHYSICAL
ACTIVITY, SITTING, STANDING, WALKING, BENDING, LYING DOWN, BOWEL MOVEMENT,
SNEEZING, COUGHING, OTHER: ____________________________________________________________________________
11. Circle what your pain limits: WORK SLEEP
DAILY ACTIVITIES RECREATIONAL ACTIVITIES
12. Has your pain become more severe? YES / NO
13. What caused it to become more severe, and when?
______________________________________________________________________________________
14. Do you have any areas of tingling (pins and needles) and numbness
(loss of sensation)? YES / NO Where? ______________________________________________________________________________________
15. Do you have any weakness in your arms, legs hands or feet? YES
/ NO Where? ______________________________________________________________________________________
16. Circle treatments you have had for your pain: PHYSICAL THERAPY,
CHIROPRACTIC, TENS UNIT,MASSAGE THERAPY, TRACTION, ACUPUNCTURE, NERVE
BLOCKS, EPIDURAL INJECTIONS, TRIGGER POINT INJECTIONS, PSYCHOTHERAPY, SURGERY, BIOFEEDBACK,
OTHER ____________________________________________________________________________
17. Since your pain problem started have you developed loss of bowel or
bladder control? YES / NO
18. Do you have Carpal Tunnel Syndrome? YES / NO
19. PAST MEDICAL HISTORY:
Circle any of the following illnesses you have had: STROKE, HYPERTENSION,
HEART ATTACK, HEART DISEASE, HIGH CHOLESTEROL, EMPHYSEMA, BRONCHITIS, DEPRESSION, ANXIETY,
HEARTBURN - ACID REFLUX, ULCERS, IRRITABLE BOWEL SYNDROME, EPILEPSY, SEIZURE,
DIABETES, ENDOMETRIOSIS, CANCER, ARTHRITIS, HEPATITIS - TYPE, AIDS, HERPES, BLEEDING
PROBLEMS, GLAUCOMA, HYPOTHYROIDISM.
Please list all other illnesses: ___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
20. SURGERY HISTORY: Surgeries,Type of Surgery, Date of Surgery
1._________________________________________________________________________________
2._________________________________________________________________________________
3._________________________________________________________________________________
4._________________________________________________________________________________
5._________________________________________________________________________________
6._________________________________________________________________________________
7._________________________________________________________________________________
8._________________________________________________________________________________
9._________________________________________________________________________________
10.________________________________________________________________________________
21. FAMILY HISTORY: Age and state of health, or Age at Death and Cause of Death
FATHER: Alive/Deceased: ______________________________________________________________________________________
MOTHER: Alive/Deceased: ______________________________________________________________________________________
BROTHERS: Alive/Deceased: ______________________________________________________________________________________
SISTERS: Alive/Deceased: ______________________________________________________________________________________
22. ALLERGIES: List medicines and types of reactions: eg: nausea, itching, rash, hives, wheezing, palpitations, passing out, other
Medication and Reaction to Medication
1. ________________________________________________________________________________
2._________________________________________________________________________________
3._________________________________________________________________________________
4._________________________________________________________________________________
5._________________________________________________________________________________
6._________________________________________________________________________________
7._________________________________________________________________________________
23. Are you presently taking ASPIRIN, COUMADIN, TICLID, LOVENOX, PLAVIX, ANTI-INFLAMMATORY
DRUGS or any other blood thinners? YES / NO Please circle
above, and list other blood thinners below. __________________________________________________________________
24. MEDICATIONS: Please List medications, Dosage, Times per day
1 ._________________________________________________________________________________
2 ._________________________________________________________________________________
3 ._________________________________________________________________________________
4 ._________________________________________________________________________________
5 ._________________________________________________________________________________
6 ._________________________________________________________________________________
7 ._________________________________________________________________________________
8 ._________________________________________________________________________________
9 ._________________________________________________________________________________
10 ._________________________________________________________________________________
25. SOCIAL HISTORY:
Circle your marital status: Married, Single, Divorced, Widowed, Separated
What is or was your occupation? _______________________________________________________
Circle your current employment status: Working (Part time/Full time), Sick leave, Disabled,
Retired, Unemployed, Other___________________________________________________________________
Do you smoke? YES / NO number of packs per day?
___ Chew tobacco or dip snuff? YES / NO
Smoke cigars? YES / NO number per day? ___
Do you drink alcohol? YES / NO Number of drinks per week:
_________
Have you ever been treated for alcohol or drug abuse? YES / NO If yes, explain: ___________________ ____________________________________________________________________________________
26 . SYSTEM REVIEW:
Please circle any of the following medical problems you have had:
Constitutional: Weight change, Fever/Chills, Sleep Disorder, Other _____________________________
Eyes: Double or blurred vision, Cataracts, Other ___________________________________
Ears: Nose, Throat & Mouth: Hearing Changes/ Deafness, Sore Throat, Sinusitis,
Hoarseness, Dizziness, TMJ, Mouth Ulcers, Other _______________________________________________________________
Cardiovascular: Chest pain, Passing Out, Irregular Heart Beat, Ankle Swelling, Other _______________
Respiratory: Shortness of breath, Asthma, Cough, Emphysema,
Other___________________________
Stomach or Bowel: Change in appetite, Weight change: gain or loss, Abdominal Pain, Diarrhea, Constipation,
Other ____________________________________________________________________
Kidney, Bladder and Reproductive: Incontinence, Change in
stream, Pain on urination, Urine Frequency, Prostate disease, Menstrual, Other______________________________________________
Musculo-Skeletal: Bone Pain, Sprain/Strain, Joint Pain, Joint Deformity,
Muscle Pain, Other ____________________________________________________________________________________
Skin/Breast: Rash/
Lumps/ Other ________________________________________________________
Neurological: Tremmor, Dizzy Spells, Seizures, Memory
loss, Headache, Other:__________________
Psychologic: Depression, Anxiety, Panic Attacks, Hallucinations,
Other __________________________
Endocrine: Hair loss,Thirst, Energy loss/Fatigue, Other ______________________________________
Hematologic/Immunologic: Bruising, Blood clots, Bleeding, Other _____________________________
27 . LEGAL INFORMATION:
Is your injury workman’s comp related? YES / NO
Automobile insurance related? YES / NO
Is there litigation pending with your injury? YES / NO If so, who is your lawyer? _________________________
Do you want us to share information with your lawyer if he contacts us? YES / NO Initial if yes: ________
Thank you for completing this questionnaire. At our facility you will
undergo an evaluation to determine the source of your pain and the treatment
options available. We will make every attempt to fully explain the findings
and treatment options. Possible complications vary from procedure to procedure,
but may include infection, increased pain, nerve injury, headache, nausea,
bleeding, and, very rarely, loss of life or limb. These complications
are extremely rare, but have been reported in the medical literature.
I have read the above and understand,
Print Name: __________________________________
Signature: __________________________________
Date: _______________________