EPSTEIN
page 2 / 1159 . OCR, unverified
A-. ACHE
B= BURNING
N= NUMBNESS
F.= PINS/NEEDLES
S= STABBING
0= OTHER
RIGHT
Please note if other:
I. When did the pain begin?
Duration of Pain:
Overall the pain is:
Improved
2. Quality of Pain
Sore
Sharp
Stabbing
Shooting
Unsure
Worse
Stable
(Cheek all that applies)?
Aching Burning
Dull
Tender
Tingling
Cramping
Pulling
Radiating
Throbbing
On a scale of 0 to 10, please circle your level of pain or discomfort
being none and 10 being unbearable for the following areas:
1. Neck Pain:
2. Left Shoulder Pain:
3.
Right Shoulder Pain:
4. Left Arm Pain:
5. Right Arm Pain:
6. Back Pain:
7. Left Hip/Buttock Pain: 0
8. Right Hip/Buttock Pain: 0
9. Left Leg Pain:
10. Right Leg Pain:
11. Left Foot Pain:
12. Right Foot Pain:
S
S
Physiatry/Rehab Medicine
DATE: dAhl-1 T lao
If you are not experiencing pain as a symptom,
please skip Questions 1-7.
3. What makes the pain better (cheek all that applies)?
I lent
Cold
Bend Forward
Bend Back
Change Position
Sitting
Standing
Walking
Twisting
Movement
Change in weather
Lying Supine
Rest
Valsalva
Coughing/Sneezing
Nothing
Sex
N/A
4. What makes the pain worse (check all that applies)?
I leaf
Cold
Bend Forward
Bend Back
Change Position
Sitting
Standing
Walking
Twisting
Movement
Change in weather
Lying Supine
Rest
Valsalva
Coughing/Sneezing
Nothing
Sex
N/A
EFTA00313804
--- PAGE 2 ---
5. Pain interferes with:
7.11pain limits activity, please full in all that apply:
Sleep
Appetite
Sex
I can't tolerate walking more than
blocks.
Self-Care
I lobbies
Job Performance
Driving
Social Life
Exercise
I can't tolerate sitting more than
minutes.
Lifting
household Chores
Other
Traveling
Shopping
Cooking
I can't tolerate standing more than
I can't tolerate lying more than
minutes.
minutes.
6. When Is the pain worst? (Circle one)
Morning
Afternoon
Evening
8. Do you experience weakness? Yes or
No
Night
If yes, please describe (include location)
Have you had any of the following imaging studies? If yes, please include the date.
IF SO, PLEASE FORWARD A COPY OF THE REPORT TO THE OFFICE PRIOR TO YOUR APPOINTMENT!
X-ray
Bone Scan
MRI tYtt. ILF,ao
CT scan
EMG
NICV.2 , a Oi
Below, indicate past treatments for your neck/back condition and include the date of treatment:
bR if aid
Nerve Block
Steroid Injections of
QCI1 Jtn4C
Physical Therapy
Acupuncture
Chiropractic
Other
If surgery is recommended, what would be your timeframe available for scheduling?
Psychotherapy
Surgery
Failed Medications
REVIEW OF SYSTEM%
GENERAL
ENDROCRINE
NEUROLOGICAL
Fatigue o NO o YES
Thyroid condition 7 NO 0 YES
Dizziness/Vertigo a NO o YES
Weight loss a NO a YES
Diabetes C NO Il YES
Headaches o NO a YES
Weakness a NO o YES
Other
Strokes c NO a YES
Swollen Lymph nodes a NO a YES
Seizures o NO o YES
KIDNEY
Tremor o NO o YES
HEAD
Difficulty in passing urine o NO a YES
Numbness o NO a YES
Visual problems a NO ci YES
Getting up at night to urinate o NO o YES
Ear pain, decreased hearing a NO o YES
PSYCHOLOGICAL
Difficulty swallowing o NO a YES
GASTROINTESTINAL
Anxiety o NO a YES
Other
Poor appetite C NO 0 YES
Depression a NO a YES
Indigestion or vomiting 0 NO 0 YES
Other
CHEST, HEART, AND LUNGS
Change in bowel habits 0 NO 0 YES
Shortness of breath o NO c YES
Pass blood from rectum 0 NO 0 YES
History of Cancer? Yes
No
Chest pain or pressure attacks a NO a YES
If yes, type:
Frequent cough a NO o YES
MUSCULOSKELETAL
Chemo: Yes
No
Swollen ankles a NO o YES
Decreased Range of Motion a NO o YES
Radiation: Yes
No
Valve disorder o NO a YES
Joint Swelling o NO a YES
Sleep Apnea o NO o YES
Joint Stiffness
NO
YES
Please notify the MD/NP/PA/RN If you are
DVT a NO a YES
o
a
Muscle Aches/Pains a NO o YES
pregnant: Yes
No
Stents o NO o YES
Other
EFTA00313805
--- PAGE 3 ---
Current Medication:
Dosage:
Frequency:
1.
2.
3.
4.
5.
6.
7.
8.
,octal History:
1.
Any allergies to: Shellfish
Iodine
Latex Contrast/IV dye
Allergies
Reaction
1.
2.
3.
Are you a: Current Smoker / Never Smoker / Former Smoker Quit Date:
Type:
Packs/day:
Years:
2. Do you use chewing and/or smokeless tobacco? Yes or No Have you quit? Yes or No
When?
3. Do you drink alcohol? Yes or No Type(s):
Amount:
How often:
4. Do you use illicit street) drugs? Yes or No Type(s):
Last used:
5. Marital Status: C
Married
Cohabitating
Separated
Divorced
Widowed
6. Who do you live with?
Alone
Spouse
Children Parents Other:
7. What is your occupation?
8. Are you disabled? Yes or No If yes, note disability:
Medical/Personal History:
Are you right- or left-handed? Right
Left
Ambidextrous
Past Medical History:
Past Surgical History and Dates:
Family Medical History:
Please share any other information you would like us to know:
Preferred Pharmacy:
Name:
Phone Number:
Address:
If this form was completed by someone other than the patient, please list the name, relation to the patient and the