New patient packet

• When did your pain start for the first time? *
  • How did it start?*
    Choose Suddenly Gradually
    • Any Incident that you believe might have precipitated your pain?*
      Choose Yes No
      • Please select all that applies
        Work related accident

        Car accident

        Lifting heavy object

        Fall

        Other

        
        
        When this inncident happened? *

• Please select where most of your pain is located *
  Please select where most of your pain is located
  
  

• What does your pain feel like: * Aching Burning Deep Electrical Pinching Sharp Shooting Superficial Spasm like Tingling Throbbing Tightness Other
  • Other pain description

What number would you give your pain level TODAY, on a scale from 0-10? *

0 1 2 3 4 5 6 7 8 9 10

What Number would you give your pain level, on a scale from 0-10, MOST OF THE TIME *

0 1 2 3 4 5 6 7 8 9 10

What number would you give your pain level on a GOOD DAY? *

0 1 2 3 4 5 6 7 8 9 10

How about your pain level at WORST? *

0 1 2 3 4 5 6 7 8 9 10

• Is your pain Constant / Continuous / All the time OR Intermittent / Occasional * None All the time Constant Continuous Intermittent Occasional

• What makes your pain better * None Bending forward Bending backwards Exercising Hot Shower Laying down Medication Sitting Standing Other
  • Which medicines make you feel better?
  • Other

• What makes your pain worse * None Lifting heavy object Bending backwards Bending forward Coughing Driving Exercising Walking Having a bowel movement Laying down Sitting Standing Sneezing Other
  • Other

• Any Associated Symptoms None Arm Weakness Numbness Tingling Loss of Bowel or Bladder Control Leg Weakness Loss of Consciousness Other
  • Other

This section is designed as an assessment tool to give us information on how your pain affects your everyday life. Please answer every section and mark in each section the ONE box that best applies to you.

PAIN RELATED TREATMENT HISTORY

A- Medications

• Non-Steroidal Anti-inflammatories* None Aspirin Celebrex Feldene Indocin Lodine Motrin (Ibuprofen) Naprosyn Orudis Relafen Toradol Vioxx Other
  • Other medication
  • Did it help?
    Choose Yes No
    Are you currently using it?
    Choose Yes No
    Any Side Effects?
    Choose Yes No
    • What are the side effects?

• Opioids * None Actiq Codeine Duragesic (Fentanyl) Dilaudid Lortab Morphine MS Contin Methadone Norco Oxycodone (Oxyfast) Percodan Percocet Roxanol Other
  • Other medication
  • Did it help?
    Choose Yes No
    Are you currently using it?
    Choose Yes No
    Any Side Effects?
    Choose Yes No
    • What are the side effects?

• Muscle Relaxants * None Baclofen Skelaxin Norflex Zanaflex Flexeril Robaxin Soma Valium Other
  • Other medication
  • Did it help?
    Choose Yes No
    Are you currently using it?
    Choose Yes No
    Any Side Effects?
    Choose Yes No
    • What are the side effects?

• Nerve Membrane Stabilizers (Anti-Epileptics) * None Depakote Dilantin Lyrica Neurontin Topamax Tegretol Other
  • Other medication
  • Helping?
    Choose Yes No
    Are you currently using it?
    Choose Yes No
    Any Side Effects?
    Choose Yes No
    • What are the side effects?

• Anti-Depressants * None Cymbalta Elavil (Amitriptyline) Effexor Nortriptyline Paxil Remeron Trazadone Zoloft Other
  • Other medication
  • Helping?
    Choose Yes No
    Are you currently using it?
    Choose Yes No
    Any Side Effects?
    Choose Yes No
    • What are the side effects?

• Migraine Medications * None Cafergot/Ergotamines Fiorinal Inderal Imitrex Other
  • Other medication
  • Helping?
    Choose Yes No
    Are you currently using it?
    Choose Yes No
    Any Side Effects?
    Choose Yes No
    • What are the side effects?

• Stimulants * None Dexedrine Provigil Ritalin Other
  • Other medication
  • Helping?
    Choose Yes No
    Are you currently using it?
    Choose Yes No
    Any Side Effects?
    Choose Yes No
    • What are the side effects?

• Anti-Anxiety / Sleeping Aid * None Ativan (Lorazepam) Ambien Xanax Other
  • Other medication
  • Helping?
    Choose Yes No
    Are you currently using it?
    Choose Yes No
    Any Side Effects?
    Choose Yes No
    • What are the side effects?

• Tylenol
  Choose Yes No
  • Helping?
    Choose Yes No
    Are you currently using it?
    Choose Yes No
    Any Side Effects?
    Choose Yes No
    • What are the side effects?

• Any Other Pain Related Medications:

  
  
  Add more medication
  

• Anti-Coagulants (Medications that prevent your blood from clotting)?
  Choose Yes No
  • if Yes Clopidogril Cilostazol Dalteparin Enoxaparin Fondaparinux Heparin Ticlopidine Warfarin Other
    • Other medication
  • Have You ever stopped these medications for medical procedures?
    Choose Yes No
    Prescribing Physicians Name?

PAIN RELATED TREATMENT HISTORY

B- Procedures

• Any previous Injection(s) Or Nerve Block(s)? Choose Yes No
  • if Yes, did it help the pain
    Choose Yes No
    • if Yes, for How long?
      
      What Type / Name of injection(s) did you have?
      
      When did you have it done last time?
      
    • What Type / Name of injection(s) did you have?
      
      When did you have it done?
      

C- Surgeries

• Any previous Surgeries to help your pain?
  Choose Yes No
  • if Yes, did it help the pain
    Choose Yes No
    • if Yes, for how long? in No, skip this Q
      
      What Type / Name of the surgery?
      
      When did you have it done?
      
      Name of the surgeon:
      
    • What Type / Name of the surgery?
      
      When did you have it done?
      
      Name of the surgeon:
      

D- Others

• Physical Therapy?
  Choose Yes No
  • if Yes, did it help?
    Choose Yes No
    Comment
    

• Exercises?
  Choose Yes No
  • if Yes, did it help?
    Choose Yes No
    Comment
    

• TENS?
  Choose Yes No
  • if Yes, did it help?
    Choose Yes No
    Comment
    

• Chiropractor?
  Choose Yes No
  • if Yes, did it help?
    Choose Yes No
    Comment
    

• Massage Therapy?
  Choose Yes No
  • if Yes, did it help?
    Choose Yes No
    Comment
    

• Biofeedback / Relaxation Training?
  Choose Yes No
  • if Yes, did it help?
    Choose Yes No
    Comment
    

• Other:
  

E- Clinic & Doctor

• Have you seen any Previous Pain Doctor or Pain Clinic?
  Choose Yes No
  • Please click here to list
    
    Reason for changing Pain Provider?

SOCIAL & LIFESTYLE HISTORY

SOAPP® Version 1.0 - SF

The following are some questions given to all patients at the Pain Management Center who are on or being considered for opioids for their pain. Please answer each question as honestly as possible. This information is for our records and will remain confidential. Your answers alone will not determine your treatment. Thank you.

• PLEASE LIST ALL MEDICATIONS *
  Add
  

• ALLERGIES *
  Add
  

• PAST MEDICAL HISTORY * arthritis blood clots coronary artery disease cancer diabetes fracture gastrointestinal disease hepatitis A hepatitis B hepatitis C heart attack headaches high blood pressure HIV/AIDS kidney disease lung disease/asthma neurologic disorders peripheral vascular disease pinched nerves stroke seizures stomach ulcers TMJ thyroid disease Other

• PAST SURGICAL HISTORY (ANY SURGERY IN THE PAST)

  Add More Fields
  

• FAMILY HISTORY

  Please List conditions that are running in your family: High Blood Pressure / Heart Diseases/ Diabetes / Autoimmune Diseases/ Rheumatologic Diseases/ Cancer / Back Pain / Joints Diseases..... *

  Add
  

• For your convenience, the area below can be used by you to write down any questions you might have for your doctor. *

Disclaimer
Please be advised that completing the preliminary health and insurance questionnaires does not establish a physician-patient relationship with this practice. VIPSC will review your health history and conduct an initial evaluation to determine wether (whether) our practice will be able to help you with your condition.

• Male

  
  
  

  Sex

  Female