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2022 BEST PAIN MANAGEMENT
WC English (cont.)
DG Pain Management
Patient Health History - Intake Form (cont.)
Pain Management Injections
Yes
No
Start Date
Where
Type
Area
Back Surgery
Yes
No
Start Date
Where
Type
Area
Diagnostic Testing
Have You Had an MRI taken?
Yes
No
Where
History
Allergies
Any Medical Problems
Please list all other medications you are currently taking:
Medication Name:
Medication Name:
Medication Name:
Medication Name:
Dosage:
Dosage:
Dosage:
Dosage:
Occupational History
Are you currently working?
Yes
No
When was your last day of work?
Occupation:
Job Title:
Does your pain affect your ability to perform your job?
Yes
No
History and Physical
Patient Name
Age:
Sex:
Female
Male
Height:
Weight:
Allergies
None
Yes
NKDA
Latex
Dye
Contrast
Other
Please name any other
Medications
None
Yes
Please List
Are you on blood thinners?
No
Yes
Coumadin
Plavix
Other
Other
Patient Medical History
Endocrine
Eyes
Cardio
Circulation
Neurological
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Psychiatric
Hematologic
Venous Disease
Diabetes: Insulin
Glaucoma: Narrow Angle
High Blood Pressure
Heart Surgery
Peripheral Vascular Disease
CVA/Stroke
Emphysema
Ulcers
Urination Problems
Arthritis
Depression
Low Platelets
Varicose
Diabetes: Non-insulin
Glaucoma: Wide Angle
Heart Attack
Angina
Chronic Edema
Seizures
Asthma
Heartburn/Reflux
Kidney Stones
Joint Replacement
Anxiety
Bleeding
Spider Veins
Thyroid
Valve Problem
Varicose Veins
COPD
Liver Problems
Erectile Dysfunction
Claustrophobia
Poor Clotting
Other
Name other conditions:
Surgical History
None
Yes
Type:
If yes, any difficulty with Anasthesia?
Smoking
None
Yes
How much?
Alcohol
None
Yes
How much?
Drugs
None
Yes
Family History
Continue
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