281-419-3366
Home
Services
Electrodiagnostic Medicine (EMGs)
Nonoperative Spine & Musculoskeletal Pain Management
Disability Evaluation/Impairment Ratings
Acute Inpatient Rehabilitation
About the Doctor
What is a Physiatrist?
Patient Forms
New Patient Form
Pain Questionnaire
Locations
Patient Portal
Contact Us
Pain Questionnaire
1
Patient Info
2
Treatment History
3
Pain Questionnaire
4
Pain Location
5
Medical History
6
Organ Systems
7
Family History
Name
*
First
Last
Email
*
Date of Birth
*
MM slash DD slash YYYY
Age
*
Please enter a number from
1
to
120
.
Reason for Office Visit
*
EMG
New Patient Consult
Impairment Rating
RME
Describe where you are currently having pain and how it happened
*
Referring Physician
List doctors who have treated you for this condition
Doctor's Name
Date
Have you had any of these tests?
EMG
MRI
CT Scan
X-Ray
Myelogram
Discogram
Have you had surgery for this condition?
*
Yes
No
Date(s) of Surgery
Have you had physical therapy for this condition?
*
Yes
No
Date(s) of Physical Therapy
Have you had injections for this condition?
*
Yes
No
Date(s) of Injections
Type(s) of Injections
Epidural Steroid Injections
Facet Blocks
Trigger Point
SI Joint
Radiofrequency
List medications have you been previously prescribed for this condition
What level of pain do you experience?
*
Barely Noticeable
Mild
Moderate
Severe
Very Severe
Unbearable
What is the consistency of the pain?
*
Occasional
Intermittent
Constant
How often do you expereince pain?
*
If you don't experience pain every day, estimate how many hours per week or month.
Examples
- 4 hours per day
- 3 hours per week
How long have you been disabled by pain?
*
Do you consider yourself to be disabled?
*
Yes
No
What activities make the pain worse?
Exercise (during)
Excercise (after)
Sitting
Standing
Walking
Bending Forward
Bending Backwards
Coughing
Sneezing
Other
List other activities that make the pain worse:
What reduces your pain?
Lying down
Sitting
Standing
Walking
Manipulation
Physical therapy
Pain Medication
Muscle Relaxants
Asprin
Other
Nothing
List anything else that reduces your pain:
List unusual symptoms related to your pain:
Examples: Nausea, Dizziness, Fatigue, Headaches
Location of Pain
*
Area of Body
Pain Type
Pain Level
List the areas on your body where you feel the described sensation. Add new rows with the (+) button if needed.
Pain Types
Ache, Numbness, Pins & Needles, Burning, Stabbing
Pain Level (1-10)
1 = No Pain
10 = Worst Possible Pain
List any drug allergies:
*
Including steroids, IV dye, Lidocaine. Enter "none" if none.
Medical History
High Blood Pressure
Heart Disease
Stroke
Atrial fibrillation
Diabetes
COPD
Hypothyroid
Cancer
Kidney Disease
HIV/AIDS
Other
List other past medical issues:
*
Enter "none" if none.
Is there any chance you are currently pregnant?
*
Yes
No
List all your current medications and dosages:
Medication
Dosage
Smoking History
*
Never smoked
Used to smoke
Currently smoke
How many packs per day?
Alcohol Use
*
Regular/Daily
Occasional
Never
Recreational Drug Use
*
Regular/Daily
Occasionally
Never
Constitutional
Depression
Fever
Weight loss/gain
Heart
Chest pain
Irregular heart beat
Poor circulation
Genitourinary
Bloody urine
Pain urinating
Unable to urinate
Neurological
Paralysis
Frequent headaches
Blood
Bleeding problems
Blood transfusion
Eyes
Decreased vision
Cataracts
Lungs
Shortness of breath
Wheezing
Persistent cough
Musculoskeletal
Joint swelling
Muscle aches
Joint pain
Psychiatric
Depression
Bipolar disorder
Ears, nose, throat
Loss of hearing
Sinus problems
Gastrointestinal
Stomach pain
Diarrhea
Persistent vomiting
Skin
Rash
Dryness of skin
Endocrine
Thyroid problems
Diabetes
Allergies
Allergies to food
Allergies to things other than medicine
List food allergies:
*
Enter "none" if none.
List other allergies:
Family Medical History
*
Relationship
Alive?
Age
Medical Problems
Relationship eg: Mother, Father etc.
Use the (+) button to add new rows.
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
