[go: up one dir, main page]
Scribd
Upload
525 views4 pages

Chronic Pain Patient Intake Form

This document contains a patient history sheet for a chronic pain clinic. It collects information about a patient's pain symptoms, medical history, medications, and test results. The sheet gathers details on the patient's name, age, contact information, duration and characteristics of pain, pain level ratings, associated symptoms, medication usage and effectiveness, sleep issues, aggravating and relieving factors, medical conditions, injuries, surgeries, and depression screening. Laboratory results and imaging reports are also documented. The medical plan section outlines the patient's prescribed medications, treatment response and tolerance, and plans for follow up visits.

Uploaded by

Belal N. Mahfouz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
525 views4 pages

Chronic Pain Patient Intake Form

This document contains a patient history sheet for a chronic pain clinic. It collects information about a patient's pain symptoms, medical history, medications, and test results. The sheet gathers details on the patient's name, age, contact information, duration and characteristics of pain, pain level ratings, associated symptoms, medication usage and effectiveness, sleep issues, aggravating and relieving factors, medical conditions, injuries, surgeries, and depression screening. Laboratory results and imaging reports are also documented. The medical plan section outlines the patient's prescribed medications, treatment response and tolerance, and plans for follow up visits.

Uploaded by

Belal N. Mahfouz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 4

Anesthesia, ICU and Pain Management Department

Interventional Pain Management Unit

Chronic Pain Clinic


Patient History Sheet
Provisional Diagnosis :

1- Name: Resident Name:


.. Date :
/
/ 20
2- Age : Sex : .. Religion : .. Occupation: .
3- Phone No. : .. Clinic Staff Name
..
4- Referring Physician: Bw. Height .
BMI
5- Marital Status : Single / Married / Separated / Other : 6 Duration of Pain ( Days / Months / Years ) : .
7- How would you assess your pain at this moment :
None mild
Max
0
9

2 3
10

Moderate
4

Sever

excruciating
7

8 Describe the course of the pain :


Persistent pain
without any
fluctuation
Persistent pain
with sudden sever
pain attacks

Pain attacks
without any pain in
between
Moderate pain
attacks with mild
pain in between

9- Does the pain radiate / spread from one part to other parts your body?

Anesthesia, ICU and Pain Management Department


Interventional Pain Management Unit

Never

Hard
ly
Note
d

Slightly

Moderate
ly

Strongl
y

Very
Strongly

Do you suffer from burning sensation


in the marked area
Do you suffer from pricking of needle
in the marked area
Do you find Touching ( like touching
of clothes , blankets ) in this area
painful
Do you have sudden pain attacks in
this area
Do you suffer from numbness in the
area that you marked
Does slight pressure in this area
( e.g with a finger ) trigger pain
Does Cold or Hot water increase your
pain?

11- Associated complains with pain ( Vomiting , Fever , Headache , Etc) .


12- When does pain get Worse ? ( Morning / Evening / All over the day )
13 Describe your sleep pattern :
(Wake up refreshed/ Wake up fatigued/Toss and turn frequently/Can't find a comfortable position )

14- What things increase your pain ?


( Lying / bending forward / sitting / changing of posture like sitting to standing / walking / lifting
something etc )

15-Medication used to reduce pain ? ..


16- How much relief are you getting from these medicines ? ( Not at all / Partial relief /
complete relief )
17 Do you suffer from any medical diseases ?
( DM / Hypertension / ISHD / Hypothyrodism / Hyperthyrodism /Renal or Impairment,
etc )
18 Do You have any injuries ? if yes , Please describe it. Start with date of injury

19 Do You Have any operations ? if yes , Please describe it. Start with date of injury

Not at
all

Several
Days but
less than

Several
Days but
more than

Nearly
every day

Anesthesia, ICU and Pain Management Department


Interventional Pain Management Unit
half a month

half a
month

Little interest or pleasure in doing things


Feeling down, depressed or hopeless
Finding trouble in falling or staying asleep or
sleeping too much
Feeling tired or have little energy
Poor appetite or over eating
Trouble in concentrating on things , such as reading
the newspaper or watching TV
Moving or speaking so slowly or restlessly that other
people could have noticed
Thoughts that you would be better off dead or
thoughts of killing yourself

Imaging Report

..

Labs
Date

TLC

Hb

Plts

INR

ESR

Bun/Crea
t

AST/
AlT

Other

Medical Plan and Follow Up


Date
of
visit

Medications

Tolerance

Response

Other
Measures

Anesthesia, ICU and Pain Management Department


Interventional Pain Management Unit

Other Measurements and plans

You might also like