Microsoft word - new patient questionairre _dr haydel and dr charlet_

Michael S. Haydel, M.D., FIPP
Board Certified in Interventional Pain Management and Anesthesiology Michael P. Charlet, M.D.

Today’s Date
Referring Physician____________________________
_______/_______/______ Primary Care Physician_________________________

First Name: ______________________________Last: __________________________Initial: ________ Age: ______
Mailing Address: _________________________________________________________________________________
City: _________________________________________ State:_____________ Zip: ___________________________
Home Phone#: ____________________________Cell#: __________________________ Sex: _________________
Date of Birth: ____/____/____ Marital Status __M__S__other Social Security#: ________-________-________
Present Employer: ____________________________________ Occupation: ________________________________
Employer Address: _____________________________________ Work Phone #: ____________________________
Name of Emergency Contact: ____________________________ Emergency Contact#: _______________________
How did you hear about us? ________________________________________________________________________
Who is responsible for this account? (Self, Insurance, W.C., Attorney) ___________________________________
Is litigation involved? YES or NO Claim/Policy #: ___________________________________
Ins: __________________________________________ Insured Name: __________________________________
Relationship to Insured: __________________ Insured DOB: _____/_____/______
Insured SS#: ____________________________________
Date last worked: __________________________
Date & Name of MD given previous work restriction: ______________________________________________________
Was your problem gradual?

Was your pain problem caused by an accident?

If yes, was the accident Employment related
DATE OF ACCIDENT
Accident
_______/______/______
month / day / year

State accident occurred in: ______________

Describe your pain: ____________________________________________________________________________
How frequently do you have pain? CONSTANT ________COMES & GOES _____ OTHER________
PLEASE CIRCLE THE NUMBERS YOUR PAIN RATES ON A SCALE OF 1-10:
No
Imaginable
1 2 3 4 5 6 7 8 9 10

CHECK ANY OF THE FOLLOWING SYMPTOMS YOU HAVE:
_____NUMBNESS
____ DEPRESSION
_____STABBING
_____TINGLING
____ WEIGHT LOSS _____SHOOTING
_____BURNING SENSATION ____ LOSS OF APPETITE
_____CRAMPING
_____ INABILITY TO SLEEP
____ MORE PAIN AT NIGHT _____HEADACHES
____ THROBBING
What INCREASES your pain?
______STANDING, WALKING ______BENDING (AT NECK/ WAIST)
______DAMP WEATHER
______FORWARD _____OTHER
______DRIVING
______BACKWARD

PLEASE SHADE IN, ON THE DRAWING BELOW, THE AREAS WHERE YOU FEEL PAIN:

PREVIOUS TREATMENT:

TREATMENT YES
MEDICATIONS: Prescribed
MEDICATIONS:
Prescribed by:

Previous medication taken for pain not listed above?_______________________________________________________
Are you allergic to any medications? If yes, which ones?____________________________________________________
____________________________________________________________________________________________________
Circle any anticoagulants taken (Blood Thinners) Aspirin Warfarin
Coumadin
Plavix Lovenox

SOCIAL HISTORY:
YES

SURGICAL HISTORY; DATE

REVIEW OF SYSTEMS:

MEDICAL HISTORY:

Source: http://www.painspecialty.net/pdf/New-patient-Questionnaire.pdf