NWSPM Patient Questionnaire

Patient Questionnaire

Part 1: Demographics
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
What is your main reason for being seen today?*
If you are an established patient at NWSPM, please list any medications you are taking for sleep, stress, and/or mood. If you are a new patient to NWSPM, please list all medications you are taking:*
Part 2: General Health Review
Please mark if you have/experience any of the following:

FeversMalaiseHeadachesBlurry visionAsthmaShortness of breathHeart attackArrythmiasNausea/VommittingDiahhreaOsteoporosisOsteoarthritisStrokeUrinary incontinenceBruisesAnxietyWeight gain/ lossNight sweatsDouble VisionDizzinessCOPDCongestive heart failureChest painSwelling in feet/anklesConstipationIBSMuscle diseaseSeizuresWeaknessInfectionsDepressionPTSD
Other Diagnosis & Date of Diagnosis
List all surgeries you have had, including date of surgery:
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Part 3: Domestic Situation
Marital Status *
Number of dependents living at home:*
Total number of dependents:*
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Part 4: Personal Habits
Do you exercise?*

NoNo, due to my pain levelYes, a couple times a month for 20-30 minutesYes, a couple times a week for 20-30 minutesYes, everyday for 20-30 minutes
Do you use tobacco?*

NoYes, less than one pack a dayYes, one or more packs a dayYes, chewing tobacco
Are you interested in help to stop smoking?*
Do you consume alcohol?*

NoYes, rarelyYes, once a weekYes, 2-3 times weeklyYes, everyday
Evaluate the following statements:
I have felt the need to cut down on my drinking*

YesNo
I get annoyed when others criticize my drinking*

YesNo
I have felt guilty about my drinking*

YesNo
Sometimes I need an eye-opener to steady my nerves and get rid of my hangover*

YesNo
Do you drink caffeinated bevrages?*

NoYes, one cup a dayYes, 2-3 cups a dayOther
What caffeinated beverage(s) do you drink?*
Describe your use of illicit/recreational drug use*

I have never used recreational drugsI currently use recreational drugsI have in the past, but not recently

Have use used any of the recreational drugs listed below? *

	Yes	No
Marijuana
Amphetamine
Cocaine
Heroin
Ecstasy
Prescription medication not prescribed to me

If you selected "yes" for any of the recreational drugs listed above, what is the date of last use? Please list any other recreational drugs you have used and date of use. *
Part 5: Educational History
Are you currently in school?*
What is your highest level of education? *
Occupational History
Are you currently employed?*
If you are not currently employed, when was the last time you worked?
What has been your primary occupation? What sort of work have you done?
Have you been in the military?*

YesNo (If no, please skip next five questions)
What branch of the military did you serve under?
What years did you serve (year to year)?
Did you ever experience combat while serving?

YesNo
Were you injured during you time of service?

YesNo
Did you receive disability benefits from your time of service?

YesNo
Part 6:

Mark if you have tried any of the following pain treatments and if so, did it help:

	NO, HAVE NOT TRIED	YES, HELPED	YES, SOMEWHAT HELPED	YES BUT DID NOT HELP
Surgery
Injections
Implanted devices
TENS unit
Headache/botox
biofeedback
Pain focused psychotherapy or psychotherapy
Relaxation techniques
Chiropractic
Acupunture
Massage therapy
Aquatic/ pool therapy
Physical therapy

Does your pain interfere with your quality of life in the following areas?

	YES	NO
Mobility
Mood
Physical activities
Recreation
Relationships
Sexual functioning
Sleep
Social
School/work

Is your pain made worse by anything? *
How do you cope with extreme pain? Is there anything that provides relief from your pain?*
Should be Empty:

Patient Questionnaire

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