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Saturday and Sunday - CLOSED
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info@heagpmc.com
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(919) 220-0107
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Step 1 of 5
20%
Follow Up
This questionnaire must be completed prior to your appointment with The HEAG Pain Management Center. Your careful answers will help us to understand your pain problem, and design the best treatment program for you. It is understandable that you might be concerned about what happens to the information you provide, as much of it is personal. Our records are strictly confidential and no outsider is permitted to see your case record without your written permission.
Name
DOB
*
Date of Service
*
Sex
Female
Male
Other
Current Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Phone Home
Phone Work
Mobile
*
Referring MD
Address
Street Address
Phone
Fax
Family MD
Address
Street Address
Phone
Fax
Patient Initial
*
Chief Complaint
Medication Refill
Follow Up
Plan for Surgery
Choose Areas You Feel Pain
Location of Pain
Headache
Neck
Right Shoulder
Left Shoulder
Upper Back
Mid Back
Low Back
Right upper extremities
Left upper extremities
Right lower extremities
Left lower extremities
Right Knee
Left Knee
Right Ankle
Left Ankle
Associated Symptom
Numbness
Tingling
Weakness
Swelling
Sleeplessness
Tenderness
Pain with light touch
Severity of Pain
0
1
2
3
4
5
6
7
8
9
10
Duration of Pain
Days
Weeks
Months
Years
Patient Initial
*
Quality of Pain
Intensity
Excruciating
Very Intense
Severe
Uncomfortable
Weak
Intense
Reaction
Agonizing
Intolerable
Awful
Miserable
Sensation
Stabbing
Burning
Throbbing
Numbing
Tingling
Timing of Pain
What kinds of things alleviate the pain?
Resting
Exercise
Pain Meditation
Standing
Sitting
Cold
Heat
Working
What kinds of things aggravate the pain?
Resting
Exercise
Sitting
Bending or Twisting
Ice
Heat
Goals
Did you achieve your physical goals since your last visits? (Activities that your pain prevented you from doing)
No didn't try
Almost Achieved
Achieved
Achieved and more
What new goals have you made?
Patient Initial
*
History of Present Illness – Pain Disability Index
Pain disability index: The rating scales below are designed to measure the degree to which aspects of your life are disrupted by chronic pain. In other words, we would like to know how much your pain is preventing you from doing what you would normally do or from doing it as well as you normally would. Respond to each category by indicating the overall impact of pain in your life, not just when the pain is at its worst.
For each of the 7 categories of life activity listed, please circle the number on the scale that describes the level of disability you typically experience.
A score of 0 means no disability at all, and a score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain.
Family/Home Responsibilities: This category refers to activities of the home or family. It includes chores or duties performed around the house (e.g., yard work) and errands or favors for other family members (e.g., driving the children to school).
0 - No Disability
1
2
3
4
5
6
7
8
9
10 - Worst Disability
Recreation: This category includes hobbies, sports, and other similar leisure time activities.
0 - No Disability
1
2
3
4
5
6
7
8
9
10 - Worst Disability
Social Activity: This category refers to activities that involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions.
0 - No Disability
1
2
3
4
5
6
7
8
9
10 - Worst Disability
Occupation: This category refers to activities that are a part of or directly related to one’s job. This includes nonpaying jobs as well, such as that of a housewife or volunteer worker.
0 - No Disability
1
2
3
4
5
6
7
8
9
10 - Worst Disability
Sexual Behavior: This category refers to the frequency and quality of one’s sex life.
0 - No Disability
1
2
3
4
5
6
7
8
9
10 - Worst Disability
Self‐Care: this category includes activities that involve personal maintenance and independent daily living (e.g., taking a shower, driving, getting dressed, etc.)
0 - No Disability
1
2
3
4
5
6
7
8
9
10 - Worst Disability
Life‐Support Activity: This category refers to basic life‐supporting behaviors such as eating, sleeping, and breathing.
0 - No Disability
1
2
3
4
5
6
7
8
9
10 - Worst Disability
Patient Initial
*
Review of Systems
Neurologic
Headache
Facial Pain
Vision Loss
Tingling
Numbness
Psychiatric
Depression
Anxiety
Insomnia
Nervousness
Cardiovascular
Chest Pain
Wheezing
Skipped Beats
Swelling
Renal/Liver
Frequent urination
Burning urination
Foul odor of urine
Blood in urine
Yellow jaundice
Endocrine
Hair/skin changes
Cold or heat intolerance
Frequent urinating
Excessive thirst
ENT
Hearing
Smelling
Swallowing
Hoarseness
Respiratory
Wheezing
Coughing
Sputum
Hematology/Oncology
Easy bleeding
Bruising
Do you ever feel or look pale?
Lumps or bumps that are new?
Any sores that will not heal?
GI
Belly pain
Constipation
Reflux/burning
Blood in stool
Grey or black stools
Vomiting
Nausea
Orthopedics/Rheumatology
Pain in joints
Swelling or red joints
Cool hands and/or feet
Cracking or popping joints
Constitutional
Fatigue
Weight loss/gain
Night sweats
Fevers
OB/GYN
Pregnant
Breast-feeding
Patient Initial
*
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