Part 1: Demographics
Date of Birth
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:
Shortness of breath
Weight gain/ loss
Congestive heart failure
Swelling in feet/ankles
Other Diagnosis & Date of Diagnosis
List all surgeries you have had, including date of surgery:
Part 3: Domestic Situation
Number of dependents living at home:
Total number of dependents:
Part 4: Personal Habits
Do you exercise?
No, due to my pain level
Yes, a couple times a month for 20-30 minutes
Yes, a couple times a week for 20-30 minutes
Yes, everyday for 20-30 minutes
Do you use tobacco?
Yes, less than one pack a day
Yes, one or more packs a day
Yes, chewing tobacco
Are you interested in help to stop smoking?
Do you consume alcohol?
Yes, once a week
Yes, 2-3 times weekly
Evaluate the following statements:
I have felt the need to cut down on my drinking
I get annoyed when others criticize my drinking
I have felt guilty about my drinking
Sometimes I need an eye-opener to steady my nerves and get rid of my hangover
Do you drink caffeinated bevrages?
Yes, one cup a day
Yes, 2-3 cups a day
What caffeinated beverage(s) do you drink?
Describe your use of illicit/recreational drug use
I have never used recreational drugs
I currently use recreational drugs
I have in the past, but not recently
Have use used any of the recreational drugs listed below?
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?
Yes, full time
Yes, part time
What is your highest level of education?
Are you currently employed?
Yes, full time
Yes, part time,
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?
No (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?
Were you injured during you time of service?
Did you receive disability benefits from your time of service?
Mark if you have tried any of the following pain treatments and if so, did it help:
NO, HAVE NOT TRIED
YES, SOMEWHAT HELPED
YES BUT DID NOT HELP
Pain focused psychotherapy or psychotherapy
Aquatic/ pool therapy
Does your pain interfere with your quality of life in the following areas?
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: