~
~ NYU Langone
' - - MEDICAL CENTER
Age: _ _ _ _ _ _ _ Height: _ _ _ _ _ _ _ Weight: _ _ _ _ _ __
PAIN INFORMATION
Mark all the areas on your body where you feel the described sensations. Also mark the areas of
radiation. Include all affected areas:
Pain:\\\\\\
Numbness: 000000
Tingling: xxxxxx
•
Where do you have pain?
Neck _ __ Upper Back _ __ Lower Back _ __
Right Arm _ __ Left Arm _ __ Right Leg _ __ Left Leg _ __
When did the pain first begin? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Is your current pain a result of a: Car Accident_ __ Fall- - - Work Injury__ __
Other (Please explain):
Draw a mark on the line to best describe your pain:
Your pain right now: 0 ' - - - - - - - - - - - - - - - - - ' 10
no pain worst pain
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Have you had the following done for your pain problem?
Was it successful?
Physical therapy/active exercise _yes - no _yes - no
Heat _yes no _yes no
- -
Cold _yes - no _yes - no
Manipulation (chiropractor) _yes no _yes no
- -
TENS Unit _yes - no _yes - no
Pain psychology _yes - no _yes - no
Holistic alternative medicine _yes no _yes no
- -
Spinal injections (number:_) _yes - no _yes - no
Surgery (type:_) _yes - no _yes - no
MEDICATION INFORMATION
Have you had any of the following:
Unplanned weight loss? (pounds:_ _ ) _yes - no
Weight gain? (pounds:_ _ ) _yes no
-
Night sweats? _yes - no
Flu-like symptoms? _yes - no
Trouble controlling your bladder? _yes - no
Trouble controlling your bowels? _yes - no
Bladder infections? _yes - no
Stomach pains or heartburn? _yes - no
Constipation? _yes - no
Persistent diarrhea? _yes - no
Chest pain or angina? _yes - no
Blueness or blackness in fingers or toes? _yes - no
Numbness in fingers or toes? _yes - no
Easy bruising? _yes - no
Shortness of breath? _yes - no
Skin problems? _yes - no
Skin color changes? _yes - no
Excessive hair loss? _yes - no
Changes in vision? _yes - no
Changes in hearing? _yes - no
Changes in swallowing? _yes - no
Excessive thirst? _yes - no
Frequency of urination? _yes - no
Sexual dysfunction? _yes - no
Allergic reactions? _yes - no
When was your last menstrual period?_ _ _ _ _ _ _ _ _ __ _yes - no
I am allergic to:
reaction: _ _ _ _ _ _ __
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reaction: _ _ _ _ _ _ __
Please circle if you take: Aspirin 81mg Aspirin 325mg Ibuprofen (Motrin, Advil) Naprosyn (Aleve) Celebrex
Please list all current medications/vitamins/supplements and doses:
Drug Dose Frequency Reason for Taking
PAST MEDICAL HISTORY
Please circle any of the following which you have had:
Heart Attack High Blood Pressure Heart Murmurs Palpitations
Heart Disease High Cholesterol Stroke Seizures
Diabetes Thyroid Disease Asthma Emphysema
Tuberculosis Ulcers Heartburn (GERO) Hepatitis (type: _ _)
Cirrhosis Gallstones Kidney Stones Urinary Urgency
Urinary Incontinence Urinary Retention Prostate Enlargement Gout
Arthritis HIV Infection AIDS Depression
Anxiety Panic Attacks Hemophilia Bleeding Abnormalities
Cancer (type: Other:
Please list all previous operations:
Surgery Right/Left Side Date
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Has anyone in your immediate family (mother, father, siblings, children) ever had:
Yes Who
1. A bleeding disorder or hemophilia?
2. A heart attack?
3. Heart disease ?
4. Diabetes mellitus?
5. A stroke?
6. Rheumatoid arthritis?
7. Lupus?
8. Cancer? type: _ _ _ _ __
9. Spine surgery?
10. Chronic lower back or neck pain?
SOCIAL HISTORY
Tobacco: _ _ packs daily for _ _years _ _ do not smoke
Alcohol Intake: _ _ none _ _every day _ _ 1-2 times/week _ _ 1-2 times/month
Type: _ _ _ _ _ _ _ __ how much:
----------
Recreational Drugs: none _ _every day 1-2 times/week 1-2 times/month
_ _ Past use Type:---------
Your highest e d u c a t i o n : - - - - - - - - - - - - - - - - - - - - -
Your o c c u p a t i o n : - - - - - - - - - - - - - - - - - - - - - - - -
Are you presently working? _ _ Yes _ _ No
If yes, please check one that applies:
Full time with no restrictions
_ _ Full time with restrictions
_ _ Part time with no restrictions
Part time with restrictions
_ _ Homemaker
_ _ Unemployed (not due to injury)- how long? _ _
_ _ Unemployed (due to injury)- how long? _ _
_ _ Retired
_ _ Disability
Have you attempted to return to work since the onset of pain? _ _ Yes _ _ No
Do you receive Social Security benefits? _ _ Yes _ _ No
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Do you receive Worker's Compensation benefits? _ _ Yes _ _ No
Have you been or do you plan to be involved in legal action regarding your pains? _ _ Yes _ _ No
Please list your physician's first & last name and phone number:
Primary P h y s i c i a n : - - - - - - - - - - - - - - - - - - - - - - - - - - -
Cardiologist:------------------------------
Neurologist: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pain Management P h y s i c i a n : - - - - - - - - - - - - - - - - - - - - - - - -
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