Tri-State Interventional Pain Consultants Returning Patient Form
Please fill out your form as completely and accurately as possible. Information collected on this form will only be used by Tri-State Memorial Hospital to register for your appointment unless stated otherwise and approved with your clear written consent.
Patient Information
Date
*
-
Month
-
Day
Year
Date
Patient Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Age
*
Sex
*
Male
Female
Do you have a referring physician?
*
Yes
No
Referring Physician Information:
Primary Care Physician Information:
What hurts the most? (i.e., which ailment would you like to discuss today?)
*
Please refer to the diagrams below to indicate where you are experiencing pain.
Draw on the Diagrams below where you are experiencing body pain:
Draw on the Diagrams below where you are experiencing head pain. If no head pain, leave blank.
When and how did your pain start?
*
Does your pain travel anywhere?
*
Yes
No
Where does your pain travel?
*
Please mark any of the following that you experience (check all that apply)
*
Change in bowel/bladder function
Weakness
Numbness
None of the above
Please describe your change in bowel/bladder function:
*
Please describe your weakness:
*
Please describe your numbness:
*
Which of the following describes your pain? (Check all that apply)
*
Burning
Sharp
Tingling
Aching
Throbbing
Shooting
None of the Above
Please rank the following on a scale of 0 (none) to 10 (worst imaginable):
*
0
1
2
3
4
5
6
7
8
9
10
Your pain on a good day
Your pain on a bad day
Your pain on average
Your ability to walk is:
*
Limited
Unlimited
What causes or worsens the pain?
*
What relieves the pain?
*
Therapies & Interventional Treatments:
Which of the following therapies have you tried?
*
Chiropractic
Massage therapy
Physical therapy
Injections
None of the Above
Was chiropractic therapy helpful?
*
Yes
No
Was massage therapy helpful?
*
Yes
No
Was physical therapy helpful?
*
Yes
No
Were injections helpful?
*
Yes
No
If you have gone to Physical Therapy, please answer below:
*
Does your pain significantly impair any of the following activities of daily living?
*
Getting dressed
Walking
Food preparation/clean up
Driving/riding in car
Sitting
Shopping
Housekeeping
Laundry
Ability to work
Other
None of the Above
If other, please explain:
*
Diagnostic Studies
Please indicate diagnostic studies you have had done:
*
X-rays
MRI
Bone scan
CT scan
EMG
None of the Above
Where did you have your x-rays done?
*
Where did you have your MRI done?
*
Where did you have your bone scan done?
*
Where did you have your CT scan done?
*
Where did you have your EMG done?
*
How long have you been treating this pain prior to coming here?
*
Less than 2 weeks
2 weeks
4 weeks
1 month
Longer then 1 month
Do you have any allergies?
*
Yes
No
What are you allergic to and what type of reaction have you had?
*
Are you on any medications?
*
Yes
No
Please list all current medications:
*
Are you on blood thinners?
*
Yes
No
Which blood thinner do you take?
*
Past Medical History:
Please mark all that apply.
*
Asthma
Bronchitis
Cancer
Defibrillator
Diabetes
Emphysema
High blood pressure
Glaucoma
Heart disease
Macular degeneration
Pacemaker
Stroke
Other
None of the Above
If other, please describe:
*
Past Surgeries:
Please mark all that apply.
*
Appendectomy
Gall bladder
Hernia repair
Hysterectomy
Defibrillator
Pacemaker
Stent
Hip replacement
Knee replacement
Shoulder surgery
Back surgery
Neck surgery
Other
None of the Above
Regarding your hip replacement, was it your left or right hip?
*
Regarding your knee replacement, was it your left or right knee?
*
Regarding your shoulder replacement, was it your left or right shoulder?
*
Please describe your back surgery:
*
Please describe your neck surgery:
*
Please describe what "other" surgery you had:
*
Review of Systems
Please mark the health problems you have had or currently have. You will be given room to explain any of your "Yes" answers.
Constitutional
*
Yes
No
Recent high fever
Recent weight loss
Recent weight gain
Thyroid disorder
Autoimmune disorder
Eye, Ear, Nose, & Throat
*
Yes
No
Ringing in ears
Glaucoma
Macular degeneration
Recent visual changes
Heart & Circulation
*
Yes
No
High blood pressure
Chest pain
Palpitations/fluttering of heart
Pacemaker or defibrillator
Lungs
*
Yes
No
Chronic or frequent cough
Coughing up blood
Shortness of breath
Gastrointestinal
*
Yes
No
Heartburn/reflux/ulcers
Prolonged constipation
Vomited blood/coffee ground material
Genitourinary
*
Yes
No
Recurrent bladder or kidney infections
Recent loss of bowel function
Recent loss of bladder function
Muscular and Skeletal
*
Yes
No
Arthritis
Swollen or painful joints
Gout
Fractures/broken bones
Osteoporosis (soft bones)
Neurology
*
Yes
No
Frequent headaches
Seizures
Loss of consciousness
Sudden weakness/numbness
Difficulty with walking/balance
Do you have Tuberculosis?
*
Yes
No
Do you have AIDS or HIV?
Yes
No
Do you have, or have you ever had Hepatitis?
*
Yes
No
What type of Hepatitis do you have?
*
Skin
*
Yes
No
Recent bruising easily
Delayed healing of cuts/incisions
Psychological
*
Yes
No
Anxiety
Depression
Bipolar disorder
PTSD
Schizophrenia
Other mental health problem
If you answered "Yes" to any of the Health Problems above, please explain. If you have no Health Problems, please type N/A.
*
Family History
Please mark if a family member has (had) a disease listed below. If it has a (*), please answer follow-up question.
*
Mother
Father
Brother
Sister
Grandparent
N/A
Cancer*
High blood pressure
Arthritis
Chronic pain problems*
Heart disease
Diabetes
Alcohol abuse
Drug abuse
Please enter type of cancer or type of chronic pain problem, or type N/A if not applicable.
*
Social History
Occupation
*
Education
*
Elementary
High school/GED
Some college
Bachelor's degree or higher
Marital Status
*
Married
Single
Divorced
Widowed
Disability or worker's compensation
*
Yes
No
Pending lawsuit
*
Yes
No
Do you currently smoke or chew tobacco?
*
Yes
No
If you smoke or chew tobacco, how much?
*
If you smoke or chew tobacco, how long?
*
If you do not currently use tobacco, have you in the past?
*
Yes
No
In the past, how much tobacco did you use?
*
When did you quit using tobacco?
*
-
Month
-
Day
Year
Date
Do you drink alcohol?
*
Yes
No
How much alcohol per week?
*
Do you or have you used illegal drugs?
*
Yes
No
Date of last use of illegal drugs
*
-
Month
-
Day
Year
Date
I authorize Tri-State Memorial Hospital to contact me via my provided email to receive messages regarding hospital changes, updates, service lines, provider information, or general marketing communications.
Yes
No
Submit
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