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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: Abdominal Pain Allergies Anemia Anxiety Asthma Back Pain Balance Problems Bladder Infection Bleeding Problems Breathing Difficulties Bruising Chest Pain 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