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Download 3-Pain Mgmt Patient History
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190 S Oak Ave, Bldg 2 Suite 1 Oakdale CA 95361 Phone (209) 848-8410 Fax (209) 848-0732 PATIENT HISTORY Patient Name _______________________________________________ Date __________________________ Date of Birth _______________________ Sex _______ Marital Status ________________________________ General Health Review Medical History (such as heart disease, stroke, cancer, arthritis, diabetes, hypertension, as well as psychiatric illnesses, etc.) ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Surgical History (unrelated to pain; such as appendectomy) ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Surgical History (related to pain; such as laminectomy) ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Allergies (include medication and food allergies) ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Intolerances (include side effects from previous medications, such as gastritis, nausea, constipation, etc.) ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Current Medications (include vitamins and birth control pills, if applicable) ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Do you have any of the following? (Circle all that apply) Headaches Vision Problems Hearing Problems Dizziness Difficulty Swallowing Stomach Pain Nausea Vomiting Constipation Diarrhea Page 1 of 2 Chest Pain Shortness of Breath Urinary Problems Rashes Swollen Joints 190 S Oak Ave, Bldg 2 Suite 1 Oakdale CA 95361 Phone (209) 848-8410 Fax (209) 848-0732 Chronic Fatigue Domestic Situation With whom do you live? ______________________________________________________________________ Are there any substance abuse issues in the household? Yes _____ No _____ If yes, please explain ________________________________________________________________________ Are you able to take care of yourself? Yes _____ No _____ If not, please enter caregiver name ____________________________________________________________ Work History Job Years Worked Why did you leave? ___________________________________ ________________ ____________________________________ ___________________________________ ________________ ____________________________________ Legal Matters Are you presently involved in a lawsuit? Yes _____ No _____ If Yes, please explain. __________________________________________________________________________________________ __________________________________________________________________________________________ Substance Use Which of the following drugs or substances, if any, have you used in the past? (Circle all that apply) Next to each drug or substance that you’ve circled, indicate if you used it occasionally (“O”), frequently (“F”), or continuously (“C”) Alcohol _____ Heroin _____ Other __________ (specify) Barbiturates _____ Amphetamines _____ Other __________ (specify) Cocaine _____ Marijuana _____ Other __________ (specify) Are you presently using any of the drugs or substances below? (Circle all that apply) Next to each drug or substance that you’ve circled, indicate if you used it occasionally (“O”), frequently (“F”), or continuously (“C”) Alcohol _____ Heroin _____ Other __________ (specify) Barbiturates _____ Amphetamines _____ Other __________ (specify) Cocaine _____ Marijuana _____ Other __________ (specify) Do you presently smoke cigarettes or use tobacco in any form? Yes _____ No _____ If not, did you ever smoke cigarettes or use tobacco in any form? Yes ____ No _____ How many packs do (did) you smoke a day? _____ For how many years? _____ Page 2 of 2
