Pain Center Initial Visit Evaluation Form - Emory Johns Creek Hospital

INITIAL VISIT EVALUATION
Name:___________________________ Date:__________ Weight:________ Height:_________
Allergies:___________________________________________ Contact Phone:_______________________
Which Physician referred you to us _____________________ Phone Number:_______________________
Primary care physician:_______________________________ Phone Number:_______________________
Have you ever been seen at another pain clinic ___Yes ___No. If Yes, where:______________________________
Have you been treated for any infections ___Yes ___No. If Yes, explain___________________________________
How did you hear about Emory Johns Creek Hospital Pain Center_______________________________________
RATE YOUR PAIN AS FOLLOWS: (0=NONE, 10=WORST POSSIBLE)
Average Day 0 1 2 3 4 5 6 7 8 9 10
Indicate on the drawing any areas of your body where you are currently experiencing pain:
Right
Left
Right
Left
Right
Left
Left
Right
Left
Right
Left
Right
PAIN MUSCLE WEAKNESS NUMBNESS
Explain Pain:___________________________________________________________________________
MEDICAL HISTORY – PLEASE CHECK ALL THAT YOU HAVE HAD IN THE PAST
Disabilities: □ Hearing □ Vision □ Speech
□ Walker □ Crutches □ Wheelchair
Cardiovascular: □ High Blood Pressure □ Coronary Artery Disease □ Congestive Heart Failure
□ Heat Attack □ Mitral Valve Prolapse □ Other Heart Valve Problems
□ Pacemaker □ Irregular Heart Beat □ Murmur
Pulmonary: □ Asthma □ Tuberculosis (TB) □ Pneumonia
□ Emphysema/Chronic Bronchitis
Endocrine □ Adult Onset Diabetes □ Juvenile Onset Diabetes □ Hyper or Hypo Thyroidism
Gastrointestinal: □ Hiatal Hernia □ Ulcers □Heartburn/Acid Reflux
Hepatic □ Cirrhosis of the Liver □ Elevated Liver Function Test
Infectious Diseases: □ Hepatitis A, B or C □ Current Infection □ Chronic Hepatitis
Genitourinary: □ Incontinence □ Kidney Stones □ Prostate Enlargement
□ Kidney Failure/Dialysis
Musculoskeletal: □ Arthritis □ Fibromyalgia □ Neck/Back Pain
□ Paralysis/Muscle Weakness
Neurological: □ Stroke □ Seizures □ Headaches
Ear/Nose/Throat: □ Sinus Infections □ TMJ
Psychiatric: □ Depression □ Schizophrenia □ Anxiety/Panic Attacks
□ Under Care of Psychiatrist
Hematologic/
Oncologic
□ Anemia □ Blood Clotting Problems □ Blood Clots Legs/Lungs
□ Blood Thinner Use □ Sickle Cell □ Circulation Problem
□ Cancer _________________________________________________
Dermatologic: □ Rash □ Psoriasis
Female Patients: □ Are You Pregnant ______ □ Last Menstrual Period ________ □ Birth Control Type _________
□ Check if you have had a hysterectomy or tubal ligation
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CURRENT MEDICATIONS INCLUDING OVER-THE-COUNTER, COUMADIN OR OTHER TYPE OF BLOOD THINNER, VITAMIN E
Name Dose Frequency
Prior Surgeries/Anesthesia/Pain Treatments
Approximate Date
Family History: List diseases that run in your family:________________________________________________
Social History: Smoking (Packs/Day______ Drugs____________ Alcohol Use (Amount)____________________
Occupation:_____________________ Disabled ___Yes ___No If Yes, give reason________________________
REVIEW OF SYSTEMS – PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING NOW:
Constitutional: □ Fatigue □ Drowsiness □ Weight Gain □ Weight Loss
□ Dizziness
□ Fever
Cardiovascular: □ Chest Pain □ Palpitations □ Fainting
Pulmonary: □ Shortness of Breath □ Cough □ Wheezing
Gastrointestinal: □ Nausea □ Vomiting □ Abdominal Pain
□ Heartburn □ Diarrhea □ Constipation
□ Bleeding
□ Bowel Incontinence
Genitourinary: □Difficulty Urinating □ Burning □ Urinary Incontinence
□ Frequency
□ Discharge
Musculoskeletal: □ Muscle Aches □ Muscle Weakness □ Decreased Range of Motion
□ Neck Pain
□ Back Pain
Ear/Nose/Throat: □ Sinus Infections □ TMJ
Dermatological: □ Swelling □ Rash □ Bruises □ Lesions
Psychiatric: □ Decreased Appetite □ Difficulty Sleeping □ Mania □ Paranoia
□ Depression □ Early Morning Awakening □ Agitation □ Anxiety
Hematologic: □ Bleeding Problems
Discharge Planning
Who will acompany you to the hospital on the day of your procedure __________________________
Who will assist you at home after your procedure __________________________________________
How Do You Learn Best Choose the best methods:
□ Demonstration □ Reading □ Hearing □ Diagrams □ Videos □ Pamphlets
Education: □ I have received the Pain Management guide and understand use of pain scale to evaluate intensity of
pain.
□ I have questions about the pain scale
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Signature of Patient or Person Completing Form
Date
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