New Patient Medical History Questionnaire

New Patient Medical History Questionnaire

Comprehensive Pain and Neurology Center, PLLC
Revised January 30, 2018

Your completed intake questionnaire helps our providers understand your medical history. We rely on its accuracy and completeness to provide you with the best care possible. Please take your time and if you have any questions of how to complete any part of this form inquire at our front desk or call (615) 410-4990.

Patient Name:    DOB:

Pain Description

Pain Description

Where is your pain located?

Where is your worst pain (check one location)?

When did your pain start?

How did your pain begin?

Since the beginning of your pain, has it?

When is your pain the worst?

Please check each of the following words that apply to your pain:

Use this diagram to indicate the location and type of your pain. Mark the drawing with the following letters that best describe your symptoms: N = numbness, S = stabbing/shooting, B = burning, P = pins and needles, A = aching.

Pain Rating

Check each number below to indicate the level or intensity of your pain (0=no pain, 10=worst).

Please indicate yes or no to the following questions:

Pain Relief

Medication trials and previous treatment history.

Medication Trials

Opioids

NSAIDs

Muscle Relaxers

Antidepressant/Antianxiety

Antiseizure

Pain relief from medications: Minimal Moderate Significant

Side effects with pain medications: Yes No If yes, please list

Pain relief from physical therapy: Not attempted Minimal Moderate Significant

Pain relief from chiropractor: Not attempted Minimal Moderate Significant

Pain relief from neck/back surgery: Not attempted Minimal Moderate Significant

Pain relief from psychological therapy: Not attempted Minimal Moderate Significant

Pain relief from procedures: Not attempted Minimal Moderate Significant

Procedure Treatment History

Current Medications, Allergies, and Past Medical History

Current Medications

Blood-thinners you are taking (if any):

Please list any medications you are taking on a regular basis:

Allergies

Do you have any known medication allergies? Yes No

If so, please list below:

Do you have any topical allergies? Iodine Chloroprep Latex Tape

Allergies to shellfish? Yes No

Past Medical History

Please check the following conditions/diseases that you have been diagnosed with in the past.

Other:

Please list any vitamins, natural products or over the counter medications:

Past Surgical History

Please check any surgical procedures you may have done in the past.

Recent hospitalization: Yes No

Family History

Mark all appropriate diagnoses for your biological mother and father only.

Other medical problems:

Social History

Education: GED/High School Some College College Grad Professional School Graduate School

Do you have a lawsuit/personal injury claim/worker’s compensation regarding your pain? Yes No

If so, has the lawsuit/claim been settled? Yes No

Are you using alcohol on a regular basis? Yes No

Tobacco use: Current Former Never

How many cigarettes do you smoke per day?

How often do you smoke? Everyday Occasionally

Are you interested in quitting smoking today? No Yes Yes, but not today Yes, I am getting help

How many times have you tried to quit? Never Once A few times Many

Which methods have you used?

Have you ever used street drugs on a regular basis? Yes No

History of physical abuse? Yes No

What is your marital status? Never married Married Separated Divorced Widow

Review of Systems

Is there any possibility you could be pregnant? Yes No NA

Diagnostic Tests and Imaging

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