Referring Physician Name and Number:
PCP Name and Number:
Where is your pain?
How long have you had this pain?
Did any particular event cause the pain to start?
. If yes, what:
Please place an “X” where you are experiencing pain.
Please Place experiencing pain
1 2 3 4 5 6 7
1 2 3 4 5 6 7
Does your pain travel?
. If yes, where?
Rate your pain over the last week, with 0 as no pain and 10 as the worst pain.
Worst Pain: --- 0 1 2 3 4 5 6 7 8 9 10
Least Pain: --- 0 1 2 3 4 5 6 7 8 9 10
Usually: --- 0 1 2 3 4 5 6 7 8 9 10
Right Now: --- 0 1 2 3 4 5 6 7 8 9 10
--- 0 1 2 3 4 5 6 7 8 9 10
Please mark the following items that best describe your pain.
Dull Sharp Numb Stabbing Burning Aching
Throbbing Tender Cramping Pressure Shooting Stinging
Weakness Numbness Tingling Bowel/Bladder Dysfunction No Associated Symptoms
How would you describe your pain?
When is your pain typically worse?
Morning Afternoon Night Doesn’t Matter
What makes your pain worse?
Standing Walking Sitting Bending Physical Activity Coughing Cold Heat Other
If other Then please Describe
What makes your pain better?
Being Still Standing Walking Sitting Lying down Bending Cold Heat Massage Pain medications Other
How much does the pain interfere with your life (circle one)?
0 1 2 3 4 5 6 7 8 9 10
What types of treatment have you tried? Example: Physical Therapy, Injections, Massage
What type of relief did you receive?
Excellent Good Fair Poor
Please list ALL pain medications that you are currently on or that you have ever used. (use the back of the paper if you need more space):
Are you allergic to anything?:
Reaction to allergies?:
Are you taking blood thinners (Aspirin, Coumadin, Plavix)?:
Have you been diagnosed with diabetes?:
Please check any of the following tests that you have had to diagnose your current problem.
CT Scan MRI Scan EMG
Do you have any medical problems? If so, please check:
Diabetes Hypertension Heart Disease COPD High Cholesterol Other
Have you had any surgeries? If so, please check:
Neck Surgery Back Surgery Appendectomy Gallbladder Hysterectomy C-Section Other
Do you have any of the following symptoms?
Fever Decreased Vision Decreased Hearing Chest Pain Shortness of Breath Constipation Incontinence Tingling Numbness Weakness Sleep Difficulty Depression Anxiety Other
Do you drink alcohol? :
If yes, how often? :
Do you use any illegal drugs, such as marijuana, cocaine, etc.? :
If yes, please specify :
What is your occupation?
Check Work status:
Working Unemployed Off Work Due To Pain Retired Disabled