Korunda pain management center

Korunda Pain Management Center
The following questions are designed to help your physical understand your current pain patterns and past treatment history. If you do not understand any of the following questions, please ask for assistant. Name: ___________________________________ Age: _________ DOB: _____________ Referring Physician: ________________________________________ Primary care Physician: _____________________________________ Other Important Attending Physicians: __________________________________ Allergies: __________________________________________ List of medications: (include dosage and when taken): Are you currently taking any blood thinners? Yes/No What are you taking? Coumadin, Lovenox, Aspirin, Plavix, Ticlid, Heparin, Other: How long have you been taking this medication? : _____________________________ Why were you put in this medication? : _______________________________________ Which doctor is monitoring this medication use? : _____________________________
Pain History:
Pain Diagram: Please Shade the areas of the diagram that correlate with your current pain location. In your own words, describe you pain: _______________________________________ Please circle all of the following that describe the character of your pain: Sharp, Dull, Deep, Superficial, Stabbing, radiating, Tingling, Burning, Aching, Shooting, Spasm, Numbness, and other not listed: ____________________________ Last Name: ____________________ DOB: ________________________ How long have you had this pain? : _______________________________________ On a pain scale of 0-10 (0 = none, 10 = worst pain in your life) what is the level today? 1 2 3 4 5 6 7 8 9 10 Is today a typical pain level or is this one of your good/bad days? Good/Bad/Typical What is you pain level on a bad day, if different from above? 1 2 3 4 5 6 7 8 9 10 Is the pain a result of an injury or trauma? : Yes/No If so explain: _______________________________________________________________________ What time of the day is your pain worst? _________________ The least? ____________ What makes the pain better? _________________________________________________ What makes the pain worst? _________________________________________________ Of the following, which medications have you tried for pain relief if any? (please circle) Lyrica/ Cymbalta/ Neurontin baclofen/Flexeril/Arthrotec/Mobic/Celebrex Percocet/Lortab/Vicodin/Oxycontin/Methadone/Ms Contin/Dilaudid/fentanyl Tylenol/Advil/Ibuprofen/AleveOther not listed: __________________________

What was imaged? ___________________ Date? _____________ Location where performed? __________________________________________ Do you have copies of the results? Yes/No
Date? ________ Do you have copies of the results? Yes/No
CT Scans Yes/No What was imaged? ______________________ Date? ________
Do you have copies of the results? Yes/No
What was imaged? _________________ Date? ______________ Do you have copies of the results? Yes/No
Have you had injections done in the past? Yes/No
Trigger point injections? Yes/No
Body location? ______________ Dates? ______________ Did it help? Yes/No Joint/Bursa Injections? Yes/No Joint location? _________________ dates? ____________ Did it help? Yes/No Last Name: ____________________ DOB: ____________________ Epidural Injections? Yes/No Cervical/Lumbar/Thoracic Did it help? Yes/No Dates? _________________ Who did the injections? ________________________________ Facet Injections? Yes/No Cervical/Lumbar/Thoracic Did it help? Yes/No Dates? _____________ who did the injections? __________________________ Radiofrequency Ablation? Yes/No Cervical/Lumbar/Thoracic Did it help? Yes/No Dates? ________________Who did the procedure? ___________ Botox Injections? Yes/No Body location? ___________________Did it help? Yes/No
Have you tried physical therapy? Yes/No Did it work? Yes/No
Have you tried Chiropractics/Acupuncture? Yes/No Did it work? Yes/No
Past Surgical History (please circle):
Back surgery? Yes/No Year? _______________ Surgeon? _____________________
Orthopedic? Yes/No Body region? ___________ Year? ________ Surgeon? _____ Abdominal/pelvic surgery? Yes/No Year? ___________
Other major surgeries? _______________________________________________
Past Medical History (please circle all that apply to your health)

Hypertension, Heart Attack, Chest pain, Heart failure, Pacemaker, Irregular Rhythm, Other: __________________________________________________
Hernia, Ulcers, Gastritis, pancreatitis, GERD, IBS, Diverticulitis, Colitis, hepatitis, Other: __________________________________________________
Diabetes, Tuberculosis, cancer, Thyroid, Arthritis, Fibromyalgia, Rheumatologic, Other: __________________________________________________ Eye Disorders, ear Disorders, nasal Disorders, Throat Disorders,
Other: ______________
Kidney Disease, Urinary/Bladder Infections, Incontinence, Prostatitis, Prostate Cancer, Other: ____________________________________________________ Last Name: ____________________ DOB: ____________________

Abnormal muscle function, Loss of joint function, spine/joint pain, Arthritic Pain, Joint replacement, generalized aches/pain, other: _______________________
Bleeding Disorder, Inability to control bleeding from cuts, Phlebitis/blood cuts, Transfusions, Immune problems/HIV/Aids, Other: ___________________________ Neurological:
Headaches, Seizures, Stroke/ TIA, Head injury, Epilepsy, Sleeping problems,
Other _____________
Are you currently experiencing any of the following?
Sudden weight loss, changes in sleep in pattern, panic attacks, loss of appetite, loss of
energy, anxiousness, chest pain or depression.
Family History:

Father: Alive: __________ Deceased: _________ Age: ___________ Health: ___________
Mother: Alive: __________ Deceased: _________ Age: ___________ Health: __________
Social History:

Occupation: ____________________ If retired, Prior Occupation: __________________
Unemployed: ___________________ Disabled (why?) _____________________________ Marital Status: Married: ______ Single: _______ Divorced: _______ widowed: ______ Children: Yes/ No How many? ___________ Ages: _______________________ Seasonal resident in ________________ or Full time resident in: Naples: ______Marco Island: ______Ft. Myers: _______ Bonita Springs: ____ Cape Coral: _____ Lehigh Acres: _____ Labelle: _____ Estero: ______ San Carlos Park: ____ Current or Past Smoker: _______ How Many packs a day: _______Quit Date: ______
Do you consume alcohol? Yes/No Social Yes/No

------------------------------------------ Nurses Only ------------------------------------

Weight: _____________
Pulse: _____________ Respiration: _____________

Source: http://www.korundapmc.com/patient-forms/kpmc_hp.pdf


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