Srs - forms console_apm.xls

New Patient Information Sheet
Visit Date:
Date of Birth:
Please fill in the questions below as concisely and accurately as possible.
The form may seem lengthy but it is very important to help us understand your pain complaints. This wil help us provide you with the highest level of care. Primary Care Doctor:
Doctor's Name
Doctor's Address/Phone
Referring Doctor:
Doctor's Name
Doctor's Address/Phone
Pain Medicine Doctor you have seen before:
Are there any claims pending or is this Workers Compensation related?
List areas of pain:
When did your pain begin:
How did your pain start:
Describe where your pain is:
Does your pain radiate anywhere? (Examples: into your arm, leg, chest, abdomen)
Circle the words which best describe your pain:
Is the pain intermittent?
or constant?
Date of Birth:
Circle the number between 0 - 10 that represents the intensity of your pain:
0 = No Pain
5 = Interferes with activities
10 = Worst pain imaginable
Average Pain =
Worst Pain =
What makes pain worse?
What makes pain better?
Pain Diagram:
Stabbing: / / / / /
Burning: XXXXX
Pins and Needles: 0 0 0 0
Aching/Throbbing: ^ ^ ^ ^ ^
Numbness: = = = = =
Other: …… .
Date of Birth:
What pain medications have you tried:
Medication
Still Using
Stopped Because
Date of Birth:
Please list other pain medications tried:
Medication
Still Using
Stopped Because
What treatments have you tried
Procedure
How Long Ago
Effective? (Y/N)
List ALL Surgeries:
Hospital
List ALL Medical Problems: (Include any diagnosis of anxiety or depression)
Medical Problem
Treating Doctor
Telephone Number
Date of Birth:
List ALL Medications you're taking:
Frequency
List ALL Medication Allergies
Reaction
Are you allergic to iodine or x-ray contrast?
Is your mother
List major illnesses
Age and cause of death
Is your father
List major illnesses
Age and cause of death
Divorced
Do you have any children? Please list.
Son/Daughter
Medical Problems
Are you employed?
Yes
If Yes:
What is your job?
Date of Birth:
Are you: Disability
How long ?
List your hobbies and interests:
Does your pain stop you from the things you enjoy?
Do you smoke?
If yes, how much?
Do you use any illegal drugs?
If yes, what?
Do you drink alcohol?
If yes, how much?
Have you ever felt you should cut down drinking alcohol?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning to
steady your nerves or get rid of your hangover?
Do you have any of the following symptoms:
General/Constitutional:
If yes, explain.
If yes, explain.
If yes, explain.
Skin/Allergy:
If yes, explain.
If yes, explain.
Sweating
If yes, explain.
Musculoskeletal:
Joint stiffness
If yes, explain.
Joint/bone pain
If yes, explain.
Joint swelling
If yes, explain.
Muscle cramps
If yes, explain.
Headaches
If yes, explain.
Dizziness
If yes, explain.
Fainting
If yes, explain.
Date of Birth:
Sensitivity to light
If yes, explain.
Sinus congestion
If yes, explain.
Nose bleeds
If yes, explain.
Bleeding gums
If yes, explain.
Mouth ulcers
If yes, explain.
Endocrine:
Neck swelling
If yes, explain.
Heat/Cold intolerance
If yes, explain.
Weight loss/gain
If yes, explain.
Appetite change
If yes, explain.
Male erectile problem
If yes, explain.
Abnormal Bleeding
/ Discharge Pain
If yes, explain.
Respiratory:
Wheezing
If yes, explain.
If yes, explain.
Short of breath
If yes, explain.
Cardiovascular:
Chest Pain
If yes, explain.
Palpitations
If yes, explain.
Lew Swelling
If yes, explain.
Hematological:
Easy bruising
If yes, explain.
Easy bleeding
If yes, explain.
Abnormal clotting
If yes, explain.
Lymph Nodes:
Enlargement
If yes, explain.
Tenderness
If yes, explain.
Gastrointestinal:
Difficult swallowing
If yes, explain.
Heartburn
If yes, explain.
Constipation
If yes, explain.
Diarrhea
If yes, explain.
Change in stool
If yes, explain.
Date of Birth:
Genitourinary:
Painful urination
If yes, explain.
Difficult urination
If yes, explain.
Urgency/frequency
If yes, explain.
Incontinence
If yes, explain.
Blood in urine
If yes, explain.
Neurological:
Fainting
If yes, explain.
Weakness/paralysis
If yes, explain.
If yes, explain.
Headaches
If yes, explain.
Migrains
If yes, explain.
Psychiatric:
Depression
If yes, explain.
Suicidal thoughts
If yes, explain.
If yes, explain.
Sleep disturbance
If yes, explain.
Patient Signature
Person filling in form if different from patient
Relationship
Continuation Information (if required)
Provider Signature:

Source: http://www.kurepain.com/wp-content/uploads/2011/09/NP-Forms-SRS-2012.pdf