Download Coral Desert Orthopaedics

Desert Pain Specialists
Patient Problem Detail
Name: ____________________________________________________ Birth Date: _______________________
Last
First
Middle Initial
Today’s Date: ____________________
PAIN PROFILE
Where is your pain located?
My pain has existed for? (ie.3 Years) ___ Days ___ Weeks ___ Years  Unknown  Other ____________
My pain is the result of?
 Unknown
 After lifting a heavy object
 Motor vehicle accident
 A work related accident
 Surgery __________________
 A physical altercation
 A sports-related injury
 Shingles
 Falling
 Disease ______________________ Other:
My pain is present?
 Continually
 Constantly
 Intermittently
 On a daily basis
 Only in the
 A physical altercation
 Weekly
 Only with walking
 only with activity such as ___________________________________________________________________________
My pain level is the worst in the….?
 Morning  Afternoon  Evening  Night  My pain does not vary by time of day
My pain level is the lowest in the…?
 Morning  Afternoon  Evening  Night  My pain does not vary by time of day
On a scale of 1-10 with 10 being the most extreme pain you can imagine, indicate the
severity of your pain CURRENTLY?  1  2  3  4  5  6  7  8  9  10
On a scale of 1-10 with 10 being the most extreme pain you can imagine, indicate the
severity of your pain on AVERAGE?  1  2  3  4  5  6  7  8  9  10
My pain is best described as:
 Aching  Burning  Dull  Deep  Stabbing OTHER: _________________________________________
Other signs and symptoms associated with my pain:
 Bladder/Bowel Problems
 Fever
 Itching
 Muscle Weakness
 Numbness/Tingling
 Rash
 Swelling
 Visual Disturbance
OTHER: ___________________________________________________________________________________________
- - - PLEASE COMPLETE THE OTHER SIDE OF THIS FORM - - -
The following aggravate my pain/discomfort:
 Cough/Sneeze  Sitting/driving  Standing
 Stress
 Touch
 Walking
OTHER: ___________________________________________________________________________________________
The following alleviate my pain/discomfort:
 Cold  Exercise  Heat  Lying Down/Resting
 Massage
 Sitting
 Standing
OTHER: ___________________________________________________________________________________________
The following areas of my life have been effected by my pain:
 Appetite
 Finances
 Physical Activity
 Use of Alcohol  Use of Recreational Drugs
 Work
 Relationships
OTHER: ___________________________________________________________________________________________
I have had the following treatments for my pain that were helpful:
 Acupuncture
 Chiropractic Treatment  Counseling
 Physical Therapy
 Hypnosis
 Nerve Block
 TENS Unit
 Traction
 Steroid Injection
 Surgery
 Massage
 Other Medication
 Trigger Point Injection  Pain Medication
 Heat/Ice
OTHER: ___________________________________________________________________________________________
I have had the following treatments for my pain that were NOT helpful:
 Acupuncture
 Chiropractic Treatment  Counseling
 Heat/Ice
 Hypnosis
 Nerve Block
 Occupational
 Physical Therapy
 Steroid Injection
 Surgery
 TENS Unit
 Traction
 Trigger Point Injection  Pain Medication
 Massage
 Other Medication
OTHER: ________________________________________________________________________________________
I have had the following diagnostic test for my pain:
 CT Scan  Discogram  EMG/Nerve Conduction  Lab Work
 MRI
 Myelogram
OTHER: ___________________________________________________________________________________________
Other important information:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Review of Systems:
Please mark any of the symptoms that you are currently experiencing:
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Abdominal Pain
Allergies
Anemia
Anxiety
Asthma
Back Pain
Balance Problems
Bladder Infection
Bleeding Problems
Breathing Difficulties
Bruising
Chest Pain
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Chronic Obstructive Pulmonary Disease
Cough
Depression
Dermatitis
Digestive Problems
Dizziness
Excessive Numbness
Fever
Headache
Heart Problems
Hepatitis
Immunological Disorder
 Injury/Fracture
 Joint/Muscle Pain
 Kidney Problems
 Loss of Hearing
 Numbness/Tingling
 Rash
 Seasonal Allergies
 Seizures
 Shortness of Breath
 Sinus Congestion
 Thyroid Disease
 Vision Problem