Maryland Pain Specialists, P.A.
410 825-6945
NEW PATIENT HISTORY AND PHYSICAL
Name:
(MM/DD/YY)
D.O.B.:
ate:
Gender: ( )Male
Email add ress:
Please provide the following information:
Pharmacy na m e/location/p hon e number:
( )Female
D
Referring Physician/Surgeon
:
Have you been underthe care
Chief Complaint
(Pa
Race/Ethnicity:
ofa
Pain Management
doctorwithin the past year?
()No (
)Yes
in Problem):
On what date did your pain problem begin:
Did an accident or injury cause your pain?
(
)
tlo ( )Yes, Please explain:
Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains,
and toothaches). Have you had pain, other than these everyday kinds of pain, today?
1.
2.
Yes
No
On the diagram (to the risht), shade in the
areas where you feel pain. Put an 'X'on the
area that hurts the most.
Circle the word(s) that best describe your pain:
Throbbing
Shooting
Stabbing
rp
Cramping
Gnawing
Hot/Burning
Aching
H
Tender
Splitting
Sic ke n
Sha
Tiring/Exhausting
eavy
Fea
ing
rful
Punishing/Cruel
Please rate your pain by circling the one number
24 hours.
that best describes your pain at its worst
34567
in the /ost
10
Pain as bad as
you can imagine
No
Pain
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Date:
Name:
Please rate your pain by circling the one number that best describes your pain at its least in the
lost 24 hours.
012345678910
Please rate your pain by circling the one number
012345678910
that best describes your pain on the average.
Please rate your pain by circling the one number that tells how much pain your have right now.
012345678910
What treatments or medications are you receiving for your pain?
Please list any medications or other treatments that you have tried but did not work:
ln the last 24 hours, how much relief have pain treatments or medications provided? Please circle the
one percentage that most shows how much relief you have received.
Oo/o
10
No
Relief
o/o 2Oo/o 3Oo/o 40%
50% 60% 70% 80%
90o/o
LOO%
Complete
Relief
Circle the number that describes how, during the past 24 hours, pain has interfered with each of the
following functions.
A. General activity
012345678910
Does not
lnterfere
Completely
lnterferes
B. Mood
012345678910
C. Walking ability
012345678910
D. Normal Work (includes both work outside the home and housework)
012345618910
E. Relations with other People
012345678910
F. Sleep
012345678910
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Name:
Date:
G. Enjoyment of life
0123
ls
your pain
(
) constant
or
45678910
( ) intermittent?
What makes your pain worse?
What makes your pain better?
Patient Health Questionnaire (PHQ-a)
Over the past 2 weeks have
you been bothered by these
Not at all
Several days
More days
than not
Nearly every
day
problems?
Feeling nervous, anxious, or on
edge
0
L
2
3
Not being able to stop or
control worrving
Feeling down, depressed, or
0
L
2
3
0
1,
2
3
0
1
2
3
hopeless
Little interest or pleasure in
doing things
PAST MEDICAL HISTORY
Please list all allergies you have
to medications and the reaction this medication caused:
Please list all current medical problems and past diseases:
Have you been diagnosed with a psychiatric illness such as anxiety, depression, or bipolar disorder?
Are you being treated by a psychiatrist?
( ) No ( ) Yes
Name/phone number,
Are you able to ( ) perform activities of daily living (dress, groom, etc.), ( ) walk,
( )do leisure activities, ( )work, or ( )exercise? Please check allthat applv.
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5.16.2016.dOC
PAgC 3 Of 6
Name:
Date:
Please list any previous procedures, nerve blocks or surgeries that you have had for your pain (include
dates, whether or not the therapy helped, and how long the relief lasted):
_
Please list all other surgeries that you have had:
Please circle any of the following that apply to
you:
history of cancer, unexplained weight loss,
current infection, decreased immune system, major fall or
loss of bowel
injury,
recent bladder dysfunction,
control, peri-rectal numbness, major weakness.
How satisfied are you with your pain control (circle one): completely satisfied, very satisfied, quite
satisfied, no change, dissatisfied, very dissatisfied, completely dissatisfied
SOCIAT HISTORY
Marital Status
Do you work
(circle):
( )full-time, (
Single Married Widow(er) Divorced
) part-time, or
(
) unable to work? Occupation:
( ) Part-time
( )Full-time
to: ( )illness/injury (
Not working due
Separated
Number of hours/week?
)doctor's
order
(
)Retired
(
)Disabled
For how long?
Work limitations/restrictions?
Does your.job require heavy lifting, bend ing/twisting, truck driving, or use of a jackhammer?
ls
there any litigation (lawsuit) related to this problem?
ls
this a Worker's Compensation claim?
Do you smoke?
(
Do you consume
)
No ( )Yes
( )Yes (
( )Yes (
) No
) No
Have you ever smoked?
( ) No ( )Yes
alcohol? ( ) Never ( )Socially only
Quit Date
( )Weekends (
) Daily
Do you use illegal drugs including marijuana and/or do you take prescription medications from
( )Yes, please explain:
others? ( )
No
Do you have a past or current history of alcohol or drug addiction?
( ) No (
) Yes
lf yes, please provide details:
Are there substance abuse issues in the household?
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( ) No (
) Yes, please
explain:
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Date:
Name:
FAMILY HISTORY (Please specify relation ship; example mother, father, etc.)
Heart Disease/High Blood Pressu re
Neurological Problem/Stroke
Bleeding/lmmune Disorders
Diabetes/Other (specify)
Drug/Alcohol Addiction
D ep ression/P sych iatric Disease
Arthritis
Cancer (what type)
REVIEW OF SYSTEMS
PLEASE CIRCLE ANY OF THE FOLLOWING YOU HAVE EXPERIENCED IN THE LAST MONTH:
Constitutionol: chills, fatigue, fever, unintentional weight loss
Eyes: blurred vision, eye drainage, eye pain
Eor/Nose/Throot: ear pain, nasal congestion, bleeding gums, sore throat, tooth pain
Cordioc/Voscular: chest pain, shortness of breath, palpitations, varicose veins, swelling/edema
Respirotory: cough, wheezing, labored/d ifficult breathing, sleep apnea
G/: abdominal pain, constipation, diarrhea, loss of bowel control, heartburn, nausea, vomiting
Genitourinory: painful urination, difficulty urinating, urinary incontinence
Musculoskeletol: joint stiffness, joint pain, muscle tenderness, history of fractures
lntegumentory/Skin: dry skin, rashes, itching
Neurologic: confusion, dizziness, sedation, headaches, memory loss, numbness/tingling, seizures,
tremor, muscular weakness, fa inting
Hematologic/Lymphotic: easy bruising, excessive bleeding, history of blood transfusion
Endocrine: decreased libido, temperature intolerance, irregular menses, erectile dysfunction, low energy,
osteoporosis
Allergic/lmmunologlc: hives, frequent illnesses/infections, HIV exposure, seasonal allergies
Psychiatric: anxiety, depression, crying spells, feeling stressed, loss of interest in pleasurable activities,
mood swings, poor concentration, recreational drug use, drug seeking or craving, sleep disturbance,
su icid al thoughts
Patient Signature:
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Name:
VITALS:
Date:
PUTSE
BP
RESP
WEIGHT
TEMP
Physician Signature:
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eUEST|ONAIRE 5.16.2016.doc
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