ADULT HISTORY for Pain Evaluations
(This information will be included in the final report)
Patient’s Name: _________________________________________ Age: _______ Date of Birth: ________________
Sex: _____ Education: __________ Primary Language: ______________
Secondary Language: _____________
Ethnicity Origin (Optional): Mark all that apply.
 American Indian  Asian  Black or African American  Hispanic or Latino
 Native Hawaiian or other Pacific Islander  White/Caucasian  Other
Who is your primary care physician? _________________________________________________________________
Medical diagnoses (if any):
(1) ______________________________________________________________________
(2)____________________________________________ (3) _______________________________________________
Who referred you for this evaluation: _________________________________________________________________
Briefly describe problem(s):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
When did the problem(s) begin? ______________________________________________________________________
If an accident occurred, what was the date of the accident? _______________________________________________
Is your pain/fatigue continuous or intermittent? ________________________________________________________
Describe the quality/sensation of the pain (e.g., sharp, burning): ___________________________________________
How does your condition interfere with your daily life?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________
1303 N Division Street, Suite A, Spokane WA 99202 (509)456-3600 Office (509)747-4420 Fax www.spokanebrain.com
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TREATMENT MODALITIES
What treatments have you tried in the PAST for your condition? How successful were they?
Past Treatment
Rate Symptom Relief (0-100%)
1. ______________________________________________________
_______________________________________
2. ______________________________________________________
_______________________________________
3. ______________________________________________________
_______________________________________
4. ______________________________________________________
_______________________________________
5. ______________________________________________________
_______________________________________
6. ______________________________________________________
_______________________________________
SYMPTOM SURVEY
For each symptom that applies, place a check mark on the line. Add any helpful comments next to the line.
1) CONCENTRATION AND AWARENESS
Date of Onset
 Highly distractible
____________
 Difficulty focusing
____________
 Lose my train of thought easily
____________
 Difficulty finishing what I start
____________
 Become easily confused and disoriented
____________
 Blackout spells (fainting)
____________
 My mind goes blank
____________
 Aura (strange feelings)
____________
 Don’t feel very alert or aware of things
____________
 Motor restlessness (e.g., foot tapping, difficulty sitting still)
____________
 Other concentration or awareness problems: _______________________________ ____________
1303 N Division Street, Suite A, Spokane WA 99202 (509)456-3600 Office (509)747-4420 Fax www.spokanebrain.com
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2) MEMORY
Date of Onset
 Forgetting where I leave things (e.g., keys, gloves, etc.)
____________
 Forgetting names
____________
 Forgetting what I should be doing
____________
 Forgetting where I am or what I am doing
____________
 Forgetting events that happened quite recently (e.g., last meal)
____________
 Need someone to give me a hint so I can remember things
____________
 Relying more and more on notes to remember things
____________
 Forgetting the order of things (e.g., when cooking, etc.)
____________
 Forgetting facts, but I can remember how to do things
____________
 Forgetting how to do things, but I can remember facts
____________
 Forgetting faces of people I know (when they are not present)
____________
 Frequently forgetting appointments
____________
 Other memory problems: _______________________________________
____________
3) MOTOR AND COORDINATION
Date of Onset
Side this occurs on:
Right
Left
Both



____________
 Weakness on one side of my body



____________
 Difficulty holding onto things



____________
 Tremor or shakiness



____________
 Muscle tics or strange movements



____________
 Fine motor control problems
(using a key, pencil, etc.)
 Walking more slowly than other people
____________
 Feeling stiff
____________
 Recent Falls
____________
 Balance problems
____________
 Difficulty starting to move
____________
 Jerky muscles
____________
 Muscles tire quickly
____________
 Often bumping into things
____________
 Other motor or coordination problems: ____________________________
____________
1303 N Division Street, Suite A, Spokane WA 99202 (509)456-3600 Office (509)747-4420 Fax www.spokanebrain.com
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4) SENSORY
Side this occurs on:
Right
 Loss of feeling or numbness

Left

Date of Onset
Both

____________
 Tingling or strange skin sensations



____________
 See “stars” or flashes of light



____________
 Other sensory problems: ________________________________________
____________
5) PHYSICAL
Date of Onset
 Headaches
____________
 Dizziness
____________
 Nausea or vomiting
____________
 Urinary incontinence
____________
 Loss of bowel control
____________
 Excessive tiredness
____________
 Sensitivity to bright lights
____________
 Sensitivity to loud noises
____________
 Sleep Disorder
____________
Who diagnosed your sleeping disorder? _______________________________________
Current Treatment? _______________________________________________________
 Other physical problems: _______________________________________
____________
6) BEHAVIOR
Date of Onset
Check all that apply to you in the past 6 months:
Severity: Mild Moderate Severe
 Sadness or depression



____________
 Anxiety or nervousness



____________
 Stress



____________
 Sleeping problems:



____________
 Become angry more easily
____________
 Euphoria (feeling on top of the world)
____________
 Much more emotional (e.g., cry more easily)
____________
 Feel as if I just don’t care anymore
____________
 Doing things automatically (without awareness)
____________
1303 N Division Street, Suite A, Spokane WA 99202 (509)456-3600 Office (509)747-4420 Fax www.spokanebrain.com
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6) Behavior Cont.
Date of Onset
 Less inhibited (do things I would not do before)
____________
 Difficulty being spontaneous
____________
 Change in eating habits: _______________________________________
____________
 Increase in weight: ____________
____________
 Decrease in weight: ____________
____________
 Change in interest in sex: _____________________________________
____________
 Change in energy level
____________
 Experience nightmares on a daily/weekly basis
____________
 Lack of interest in pleasurable activities
____________
 Increase in irritability
____________
 Increase in aggression
____________
 Other recent changes in behavior or personality: ____________________________________
Overall, my symptoms have developed:  Slowly  Quickly
My symptoms occur:  Occasionally  Often
Over the past 6 months my symptoms have:  Stayed the same  Worsened
 Improved
MEDICAL HISTORY
Did you ever suffer a serious injury to your head?  Yes
Was there loss of consciousness?  Yes
 No
 No
If so, for how long? ___________________________________
If yes, explain the circumstances and any problems you had afterwards:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Do you have epilepsy or a seizure disorder?  Yes
 No
1303 N Division Street, Suite A, Spokane WA 99202 (509)456-3600 Office (509)747-4420 Fax www.spokanebrain.com
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ADULT MEDICAL HISTORY (Check all that apply)













AIDS or HIV+
Allergies
Ateriosclerosis (artery disease)
Arthritis
Blood disorder
Brain disease or infection
Cancer or chemotherapy
Parkinson’s disease
Psychiatric problems
Dementia
Venereal disease
Hazardous substance exposure
Concussion

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


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Heart disease
Huntington’s disease
Hypertension
Kidney disease
Loss of consciousness
Lung (respiratory) disease
Malnutrition
Meningitis
Multiple Sclerosis
Polio
Radiation exposure or therapy
Thyroid disease
Head injury
 Any other problems: ______________________________________________________________________________
List any medications you currently take (prescribed or over-the-counter) and dosage for conditions other than pain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Are you currently in psychotherapy, counseling, or under psychiatric care?  Yes
Have you ever been in psychotherapy, counseling, or under psychiatric care?  Yes
 No
 No
If yes, when and with whom?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have you ever been prescribed psychotropic medication (e.g., antidepressant, anti-anxiety, tranquilizer)?
 Yes  No
If yes, what?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
1303 N Division Street, Suite A, Spokane WA 99202 (509)456-3600 Office (509)747-4420 Fax www.spokanebrain.com
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List all inpatient mental health hospitalizations including the name of the hospital, dates of hospitalization, duration, and
diagnosis.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have you had a prior psychological or neuropsychological evaluation?  Yes
 No
If yes, who was the psychologist? _______________________________________ Date of Evaluation: ______________
Findings of evaluation: _______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SUBSTANCE USE HISTORY
ALCOHOL USE
 I began drinking alcohol regularly at age:  Prior to age 10
 I drink alcohol:  rarely or never
 1-2 days/week
 10-15
 3-5 days/week
 16-18
 19-21  over 21
 daily
 I used to drink alcohol but have stopped. Date stopped: ___________________
Preferred types of alcoholic drinks: _____________________________________________________________________
Usual number of drinks I have at one time: _______________________________________________________________
My last drink was:  less than 24 hours ago
 24-48 hours ago
 Over 48 hours ago
Check all that apply:
 I can drink more than most people my age and size before I get drunk
 I sometimes get into trouble (e.g., fights, legal problems, conflicts, problems at work, accidents, etc.) after drinking
 I sometimes black out after drinking
1303 N Division Street, Suite A, Spokane WA 99202 (509)456-3600 Office (509)747-4420 Fax www.spokanebrain.com
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DRUG USE
Please check all the drugs you are now using or have used in the past:
Presently using
Used in past
Amphetamines (including diet pills)


Barbiturates (downers, etc.)


Cocaine or crack


Hallucinogenics (LSD, acid, STP, etc.)


Inhalants (glue, nitrous oxide, etc.)


Marijuana


Opiate Narcotics (heroin, morphine, etc.)


PCP (angel dust)


Other recreational drugs: _____________________________________________________________________________
Do you consider yourself dependent on any of the above substances?  Yes
Do you consider yourself dependent on any prescription drugs?  Yes
 No
 No
Check all that apply:
 I have gone through drug withdrawal
 I have used I.V. drugs
 I have been in drug/alcohol treatment
Have you ever used tobacco?  Yes
Date/Location: _________________________________________________
 No
If you currently use tobacco, what is the amount per day? _____________
Do you drink caffeinated beverages?  Yes
 No
Date Quit:___________________________
Amount per day____________
1303 N Division Street, Suite A, Spokane WA 99202 (509)456-3600 Office (509)747-4420 Fax www.spokanebrain.com
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LEGAL/CRIMINAL HISTORY
Are you currently in litigation?  Yes
 No
If so, is it related to this evaluation/injury?  Yes
Have you been involved in litigation related to your pain condition?  Yes
 No
 No
If yes, explain briefly: _______________________________________________________________________________
Describe any history of arrests, charges, convictions:
__________________________________________________________________________________________
FAMILY HISTORY
Marital status:  Single
 Partnered
 Married
 Divorced
 Widowed
How many times have you been married? _____________
How many children do you have?
 Girls
Ages_________________________
 Boys
Ages_________________________
EDUCATIONAL HISTORY
Highest grade or degree you’ve earned? _______________________________________________________________
Were you ever held back to repeat a grade?  Yes
 No If yes, what grade? __________ or age? __________
Were you ever in any special class (es) or did you receive special education services?  Yes
If yes, what grade? ___________
or age? ____________
 No
What type of class? ________________________________
OCCUPATIONAL HISTORY
Current job title: _________________________________________________
Years in this position: ____________
Current job responsibilities: _________________________________________________________________________
Prior jobs (start with most recent):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
1303 N Division Street, Suite A, Spokane WA 99202 (509)456-3600 Office (509)747-4420 Fax www.spokanebrain.com
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RECREATION
Briefly list the types of recreation you enjoy:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
OTHER INFORMATION
Please provide other information you think may be important:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Thank you for taking the time to carefully complete this questionnaire.
1303 N Division Street, Suite A, Spokane WA 99202 (509)456-3600 Office (509)747-4420 Fax www.spokanebrain.com
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