Patient Information
Full name
*
Date of birth
*
Phone number
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Email address
*
Primary care provider
*
Type N/A if this does not apply to you.
Referring provider
*
Type N/A if this does not apply to you.
Preferred pharmacy (name and location)
*
Insurance Information
Insurance provider
*
Insurance ID / Member ID
*
Exactly as printed on your insurance card.
Group number
*
Type N/A if your card has no group number.
1. Main Pain Concern
Main reason for your visit today
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Where is your pain located?
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Head / face
Neck
Shoulder
Arm / elbow
Hand / wrist
Upper back
Mid back
Lower back
Hip
Buttock
Leg / knee
Foot / ankle
Chest
Abdomen
Widespread / all over
Select all that apply.
When did this pain start?
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When did this pain start?
Was there an injury, accident, fall, or surgery related to this pain?
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Was there an injury, accident, fall, or surgery related to this pain?
2. Pain Severity and Pattern
Your pain RIGHT NOW
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Your pain RIGHT NOW
WORST pain this week
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WORST pain this week
BEST pain this week
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BEST pain this week
AVERAGE pain this week
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AVERAGE pain this week
How often is the pain present?
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Constant
Most of the day
Comes and goes
Only with certain activities
Only at night
How would you describe the pain?
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Aching
Burning
Sharp / stabbing
Shooting
Throbbing
Cramping
Numbness
Tingling
Electric shock
Dull / pressure
Stiffness
Select all that apply.
3. Symptoms and Impact on Daily Life
Do you also have any of the following with your pain?
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Weakness
Numbness
Tingling
Loss of balance
Falls
Bowel or bladder changes
Fever
Unexplained weight loss
Night sweats
None of these
Select all that apply.
What makes the pain better?
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What makes the pain worse?
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Which activities are affected by your pain?
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Walking
Standing
Sitting
Bending
Lifting
Sleeping
Driving
Work
Exercise
Household chores
Self-care / dressing
Mood / concentration
Select all that apply.
4. Pain Location Map
FRONT of body - mark all painful areas
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Head / face
Neck
Chest
Abdomen
Right shoulder
Left shoulder
Right arm
Left arm
Right hand
Left hand
Right hip
Left hip
Right thigh
Left thigh
Right knee
Left knee
Right foot
Left foot
No pain on the front
Select all that apply.
BACK of body - mark all painful areas
*
Back of head
Neck
Upper back
Mid back
Lower back
Right buttock
Left buttock
Right shoulder blade
Left shoulder blade
Right arm
Left arm
Right thigh
Left thigh
Right calf
Left calf
Right heel
Left heel
No pain on the back
Select all that apply.
5. Prior Evaluation and Treatment
Imaging for this pain in the last 2 years
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X-ray
MRI
CT scan
Ultrasound
EMG / nerve study
Bone scan
None
Select all that apply.
Where and when was the imaging done?
*
Type N/A if this does not apply to you.
Upload MRI report (optional)
Upload MRI report (optional)
Accepted formats: PDF, JPG, JPEG, PNG, or GIF.
Treatments you have tried for this pain
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Physical therapy
Chiropractic
Massage
Acupuncture
Steroid injections
Epidural injection
Radiofrequency ablation
Spinal cord stimulator
Surgery
TENS unit
Home exercise
Heat / ice
Bracing
Pain psychology
None
Select all that apply.
What helped, if anything?
*
Type N/A if this does not apply to you.
6. Medications Tried
Anti-inflammatory / non-opioid
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Ibuprofen (Advil, Motrin)
Naproxen (Aleve)
Meloxicam (Mobic)
Diclofenac (Voltaren)
Celecoxib (Celebrex)
Acetaminophen (Tylenol)
Aspirin
None
Select all that apply.
Antidepressants used for pain
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Duloxetine (Cymbalta)
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Venlafaxine (Effexor)
None
Select all that apply.
Muscle relaxants
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Cyclobenzaprine (Flexeril)
Tizanidine (Zanaflex)
Baclofen
Methocarbamol (Robaxin)
Metaxalone (Skelaxin)
None
Select all that apply.
Nerve / anti-seizure medications
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Gabapentin (Neurontin)
Pregabalin (Lyrica)
Topiramate (Topamax)
Carbamazepine (Tegretol)
None
Select all that apply.
Opioids
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Tramadol (Ultram)
Hydrocodone (Norco, Vicodin)
Oxycodone (Percocet, OxyContin)
Morphine
Hydromorphone (Dilaudid)
Fentanyl patch
Methadone
Buprenorphine (Butrans, Belbuca)
None
Select all that apply.
Current pain medications and dose (if known)
*
Type N/A if this does not apply to you.
Other medications tried, or side effects you experienced
*
Type N/A if this does not apply to you.
Do you take a blood thinner?
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Do you take a blood thinner?
7. Medical and Social Information
Do you have diabetes?
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No
Type 1
Type 2
Pre-diabetes
Not sure
Symptoms or conditions you currently have
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High blood pressure
Heart disease
Stroke
Asthma / COPD
Sleep apnea
Kidney disease
Liver disease
Thyroid disease
Cancer
Osteoporosis
Arthritis
Autoimmune disease
Depression
Anxiety
PTSD
Bleeding disorder
Active infection
Pregnancy
None of these
Select all that apply.
Tobacco use
*
Never
Former
Current - cigarettes
Current - vaping
Other
Alcohol use
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Never
Occasionally
Weekly
Daily
Former - in recovery
Alcohol - drinks per day or per week
*
Type N/A if this does not apply to you.
Recreational drug use
*
Never
Former
Current
Prefer not to answer
Recreational drug use - what and how often
*
Type N/A if this does not apply to you.
Employment status
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Employment status
Occupation
*
Type N/A if this does not apply to you.
Hand dominance
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Right
Left
Ambidextrous
8. Signature
Type your full legal name as your signature
*
Today's date (MM/DD/YYYY)
*
I certify the information provided is true and complete to the best of my knowledge.
*
I certify this information is true and complete
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