Las vegas pain control associates

Joseph Schifini, M.D.
DATE ____/____/____

PLEASE FILL OUT THIS FORM COMPLETELY SO WE CAN HELP YOU WITH YOUR PAINFUL CONDITION.
NAME:_____________________________ AGE:_____
HEIGHT ___'___" WEIGHT______lbs
OCCUPATION:__________________________________________ DATE LAST WORKED____/____/____
CC:
WHY WERE YOU REFERRED TO OUR CLINIC?______________________________________________________
PLEASE DESCRIBE YOUR PAIN BY SHADING IN THE AFFECTED AREAS AND PLACING AN 'X' ON THE
AREA THAT HURTS THE MOST. CIRCLE ALL APPLICABLE DESCRIPTIVE WORDS.

CONSTANT
TEMPORARY
OCCASIONAL
SHOOTING
STABBING
TINGLING

PINS/NEEDLES

PLEASE ATTEMPT TO QUANTIFY YOUR PAIN USING PERCENTAGES. YOUR TOTAL PAIN SHOULD ADD UP
TO 100%. ( EXAMPLE: 20% LOW BACK PAIN AND 80% RIGHT LEG PAIN = 100%.)
HEAD_____%
NECK_____%
RIGHT ARM_____%
LEFT ARM_____%

CHEST_____%
ABDOMEN_____%
UPPER BACK_____%
MID BACK_____%

LOWER BACK_____% HIPS/BUTTOCKS_____%
RIGHT LEG_____%
LEFT LEG_____%

CIRCLE THE ACTIVITIES WHICH TEND TO INCREASE YOUR PAIN:

WALKING
TWISTING
STANDING

FILL IN ACTIVITIES WHICH DECREASE YOUR PAIN:__________________________________________________________
DOES THIS PAIN AFFECT YOUR SLEEP? YES / NO
CURRENT PAIN MEDICATIONS:_________________________________________PRESCRIBED BY DR._________________
MARK YOUR AVERAGE PAIN SCORE:
0-----------1-----------2-----------3-----------4-----------5-----------6-----------7-----------8-----------9-----------10
MARK YOUR WORST PAIN SCORE:
0-----------1-----------2-----------3-----------4-----------5-----------6-----------7-----------8-----------9-----------10
NOTE: (ZERO EQUALS NO PAIN AND TEN EQUALS YOUR WORST IMAGINABLE PAIN)
WHEN DID THIS PAIN BEGIN?_________ (SPONTANEOUS/ INJURY/ ACCIDENT/ SURGERY/ OTHER)
PLEASE DESCRIBE HOW IT BEGAN:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
HAVE YOU EVER HAD ANY ACCIDENTS OR INJURIES AFFECTING THESE SAME AREAS BEFORE? YES / NO
IF YES, WHEN?__________________________________________________________________________________________
TREATMENT: WHICH TYPES OF TREATMENT HAVE YOU HAD IN THE PAST TO TREAT YOUR CURRENT PAIN.
PLEASE CIRCLE ALL THAT APPLY.

PAIN CLINIC PHYSICAL THERAPY MASSAGE CHIROPRACTIC INJECTIONS SURGERY
ACUPUNCTURE MAGNETS HERBS OTHER:_______________________________________________________
PLEASE LIST ALL TREATMENT BELOW:
HEALTH CARE
APPROXIMATE DIAGNOSIS
TREATMENT/
PROFESSIONAL DATES
MEDICATIONS

DIAGNOSTIC EXAMINATIONS:
PLEASE CIRCLE ALL THAT APPLY

XRAY CT-SCAN MRI MYELOGRAM EMG/NCV OTHER___________________________________________________
PAST/CURRENT MEDICAL HISTORY:
PLEASE CIRCLE ALL THAT APPLY:

ARTHRITIS ASTHMA BLEEDING PROBLEMS CANCER CIRRHOSIS COLITIS DIABETES EMPHYSEMA
HEART TROUBLE HEPATITIS / JAUNDICE HIGH BLOOD PRESSURE HIV / AIDS KIDNEY DISEASE
MURMUR SEIZURE STROKE THYROID TROUBLE URINATING ULCER VASCULAR DISEASE
ARE YOU TAKING ANY BLOOD THINNERS SUCH AS COUMADIN, WARFARIN, PLAVIX, OR TICLID? YES / NO
LIST ALL CURRENT MEDICATIONS:________________________________________________________________________

ALLERGIES TO MEDICATIONS:_____________________________________________________________________________
PAST SURGICAL HISTORY: (PLEASE LIST ALL OPERATIONS YOU HAVE HAD)________________________________
__________________________________________________________________________________________________________
SH: SINGLE____ MARRIED____ DIVORCED____ SEPARATED____ WIDOWED____ # OF CHILDREN_____
PACKS OF CIGARETTES SMOKED/DAY_________
# OF ALCOHOLIC BEVERAGES/DAY_________
HISTORY OF SUBSTANCE ABUSE YES / NO IF YES, WHAT TYPE?_____________________________________________

FH: LIST ANY ILLNESSES WHICH RUN IN YOUR FAMILY: ___________________________________________________
ROS: PLEASE CIRCLE ALL SYMPTOMS YOU MAY CURRENTLY HAVE:
CHANGE IN VISION CHEST PAIN
COUGH DIARRHEA / CONSTIPATION DIZZINESS EASY BLEEDING FAINTING FEVER ITCHING
SHORTNESS OF BREATH STOMACH PROBLEMS URINARY PROBLEMS WEIGHT LOSS / WEIGHT GAIN
WHO IS YOUR CURRENT PRIMARY CARE PHYSICIAN / PROVIDER:__________________________________________

Source: http://www.painsolutions.com/forms/JJS%20LVPCACON%20-%20English.pdf