Form Six | HEAG Pain Mangement Center, P.A.

The best pain management clinic in the south

Patient Forms | Schedule An Appointment: (919) 220-0107

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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.
Name
DOB*
Date of Service*
Sex
- Female
- Male
- Other
Current Address*
Street Address City State / Province / Region ZIP / Postal Code 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 – Activity Interference Index
a) Normal Daily Activities
- 0 - Does not Interfere
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Completely Interferes
b) Mood
- 0 - Does not Interfere
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Completely Interferes
c) Walking Ability
- 0 - Does not Interfere
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Completely Interferes
d) Normal Work (includes both work outside the home and housework):
- 0 - Does not Interfere
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Completely Interferes
e) Sleep
- 0 - Does not Interfere
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Completely Interferes
f) Family Relationship
- 0 - Does not Interfere
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Completely Interferes
g) Relationship with your spouse/partner
- 0 - Does not Interfere
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Completely Interferes
h) Social activities with other people
- 0 - Does not Interfere
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Completely Interferes
i) Enjoyment of life
- 0 - Does not Interfere
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Completely Interferes
Patient Initial*

History of Present Illness – Analgesia
1. What percentage of your pain has been relieved during the past week?
- 0%
- 10%
- 20%
- 30%
- 40%
- 50%
- 60%
- 70%
- 80%
- 90%
- 100%
2. Is the amount of pain relief you are now obtaining from your current pain reliever(s) enough to make a real difference in your life?
- Yes
- No
3. Do you think you benefit from the prescribed medications?
- Yes
- No
Activities of Daily Living

Please indicate whether you are functioning Better, the Same, or Worse with your current pain reliever(s) since the last assessment.
1. Physical Functioning
- Better
- Same
- Worse
2. Family Relationships
- Better
- Same
- Worse
3. Social relationship
- Better
- Same
- Worse
4. Mood
- Better
- Same
- Worse
5. Sleep patterns
- Better
- Same
- Worse
6. Overall functioning
- Better
- Same
- Worse
Adverse Effect

Are you experiencing any side effects from your current medications?
Nausea
- None
- Mild
- Moderate
- Severe
Vomiting
- None
- Mild
- Moderate
- Severe
Constipation
- None
- Mild
- Moderate
- Severe
Itching
- None
- Mild
- Moderate
- Severe
Confusion
- None
- Mild
- Moderate
- Severe
Sweating
- None
- Mild
- Moderate
- Severe
Fatigue
- None
- Mild
- Moderate
- Severe
Drowsiness
- None
- Mild
- Moderate
- Severe
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*

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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