The best pain management clinic in the south
Patient Forms | Schedule An Appointment: (919) 220-0107
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Step 1 of 7

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  • 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.

  • Duration of Pain

  • Quality of Pain

  • Timing of Pain

  • Goals

  • 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.

  • Dizziness Questionnaire

  • II. When you are “dizzy” do you experience any of the following sensations? You may circle as many yes responses as necessary.

  • III. Please fill in the blanks or circle the appropriate answer.

  • times per day / week / month / year.
  • seconds / minutes / hours / days.

  • IV. Do you have any of the following symptoms? Please circle Yes or No and circle the ear involved.

  • V. Have you experienced any of the following symptoms?

  • Review of Systems

HEAG Pain Management Center

HEAG pain clinics are committed to meeting our patient’s individual needs by providing them with high-quality care to improve their quality of life. In addition to routine office visits, services may include medication management, injections, procedures and opioid abuse counseling services.

Our providers evaluate each patient and support an overall health and wellness approach.

Durham Location

2609 N. Duke St., Suite 303-B

Durham, NC 27704

Phone: (919) 220-0107

Fax: (919) 220-7623

Greensboro, NC

203 Pomona Drive

Greensboro, NC 27408

Phone: (336) 282-0132

Fax: (336) 282-6962

 

Greenville, NC

2245 H Stantonsburg Road,

Greenville NC 27832

Phone: (252) 364-2830

Fax: (252) 364-2832

Archdale, NC

106 Baker Road

Archdale, NC 27263

Phone: (336) 434-3435

Fax: (336) 434-3437

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