NEUROSCIENCE & PAIN CENTER...15.In the past 30 days, how often have you borrowed pain medication...
Transcript of NEUROSCIENCE & PAIN CENTER...15.In the past 30 days, how often have you borrowed pain medication...
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(xxx)xxx-xxxx
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O Male
O Female
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SEGURA NEUROSCIENCE & PAIN CENTER
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Dominant Hand
0 Right
0 Left
Chief Complaint:
In your own words, why are you here today ...
Pain Score 1 - 10
@l
0 2
0 3
04
0 5
0 6
O 7
0 8
O 9
O 10
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Quality of Pain: (please choose all that apply to your pain)
D Tenderness D
0 Aching D
D Burning D
D Cramping D
D Muscle weakness D
D Pins/needles D
Referring Physician
How did you hear about us?
When did the pain start?
Where is it located?
Does it radiate into your arms?
0 No
O Yes, right arm
O Yes, left arm
O Yes, both arms
Does it radiate into your legs?
0 No
O Yes, right leg
O Yes, left leg
O Yes, both legs
Pressure
Shocking
Shooting
Spasms
Stabbing
Stinging
0 Throbbing
D Tightness
0 Tingling
0 Other
3
Was this due to a MVA or Work Injury?
What makes the pain BETTER?
What makes the pain WORSE?
Do you sleep well?
O Yes
0 No
Do you fall asleep easily?
O Yes
0 No
Do you wake up easily?
O Yes
0 No
Do you have any numbness?
O Yes
0 No
If yes, where?
Do you have any weakness?
O Yes
0 No
If yes, where? 4
Do you have any bladder or bowel incontinence?
O Yes
0 No
Have you had surgery for your pain?
Past Treatments:
D Nerve Blocks
D Epidural Steroid Injection
D Chiropractor
D Physical Therapy
O Other
Other Treatment: With Whom/ How Long Ago?
Radiology Testing
D Xrays
0 MRI
0 CT Scan
Radiology Test - Where/ Date:
Smoker:
O Yes
0 No
O Quit
Packs per day:
Number of years: 5
Alcohol:
O None
O Occasional
0 Daily
How much per week:
Recreational Drugs:
O Yes
0 No
Do you have any history of prescription medication Abuse/Overuse
O Yes
0 No
Do you have any history of addiction:
O Yes
0 No
Working status:
O Currently working
O Retired
O Unemployed
0 Disabled
Occupation:
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Please select if you have any of the following:
D Anxiety
D Depression
D Memory Loss
D Suicidal Ideation
0 ADHD/ADD
O Other
Other:
ALLERGIES:
Med i cation: _________________ Re action: _________________________ _
SURGICAL HISTORY
Year: __________ Describe: ___________________ Doctor: _________ _
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Current Medications: List all medications you are currently taking including over the
counter medication, herbs, and vitamins. Include: Medication Name I Strength I Dose
I Prescriber
Med Name: _____________ St re n gt h: _________ Dose: _________ pre sc ri be r: ____________ _
Family Medical History: Please list any outstanding medical conditions:
Mother
Father
Siblings
Maternal Grandfather
Maternal Grandmother
Paternal Grandfather
Paternal Grandmother
Other: 9
REVIEW OF SYSTEMS: Please select if you have or had any of the following:
General
D Weight change
D Poor or changed appetite
D Severe fatigue / low energy
D Recent fevers
D Recent antibiotics
Hematological
D Anemia
D Easy bruising
D Bleeding disorder
D Taking blood thinners
D Blood transfusion
D Cancer
Skin
D Rash
D Nail changes
D Bumps/nodules
Head and Neck
D Headaches
D Visual changes
D Mouth problems
D Neck pain
D TMJ problems
10
Cardiac
D Chest pain
D Irregular heartbeat
D Heart murmurs
D High or low blood pressure
D Circulation problems
D Ankle swelling
Pulmonary
D Shortness of breath
0 Cough
D Asthma or bronchitis
D Lung disease
D Sleep apnea
D Snoring
Endocrine
D Diabetes
0 Thyroid problems
Gastrointestinal
D Adominal pain
D Nausea or Vomiting
D Constipation
D Diarrhea
D History of ulcers
D Reflux
D Heartburn
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Genitourinary
D Frequent or hesitant urination
D Pain with urination
D Blood in urine
D Incontinence
D Sexual dysfunction
Musculoskeletal
0 Arthritis
D Osteoporosis
D Muscle pain
D Muscle wasting
D Fractures
Neurologic
D Numbness
D Weakness
D Falling
D Stroke
D Seizures
D Memory loss
D Loss of balance
Infectious Diseases
D Measles
D Mumps
D Chicken pox
D Rheumatic fever
D Hepatitis A
D Hepatitis B
D
D
D
D
D
D
D
Hepatitis C
HIV
AIDS
Herpes (oral)
Herpes (gential)
Shingles
Post-herpatic neuralgia
Gynecologic
D Pregnant
D Post Menstrual Period
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IT IS SEGURA NEUROSCIENCE AND PAIN CENTER'S PRACTICE NOT TO PRESCRIBE
BENZODIAZEPINES (XANAX, ATIVAN, VALIUM, KLONOPIN) AND SOMA. BY CHECKING
BELOW YOU ACKNOWLEDGE THAT YOU UNDERSTAND AND ARE AWARE THAT EXTREME
SLEEPINESS, RESPIRATORY DEPRESSION, COMA, AND DEATH CAN OCCUR WITH THE USE
OF THESE MEDICATIONS AT THE SAME TIME.
Clinical guidelines from the U.S. Centers for Disease Control and Prevention (CDC) and
existing labeling warnings regarding combined use caution prescribers about co
prescribing opiods and benzodiazepines to avoid potential serious health outcomes. The
actions of the FDA today are consistent with the CDC.
There are dangers of certain medication interactions with chronic opioid use.*
O Yes, I understand
COMM
Please answer each question as honestly as possible. Keep in mind that we are only
asking about the past thirty days. There are no right or wrong answers. If you are
unsure about how to answer the question, please give the best answer you can.
1. In the past 30 days, how often have you had trouble thinking clerarly or
had memory problems?
O Never
O Seldom
O Sometimes
O Often
O Very Often
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2. In the past 30 days, how often do people complain that you are not completing
necessary tasks? (i.e., doing things that need to be done, such as going to class,
work, or appointments)
O Never
O Seldom
O Sometimes
O Often
O Very Often
3. In the past 30 days, how often have you had to go to someone other than your
prescribing physician to get sufficient pain relief from medications? (i.e., another
doctor, the Emergency Room, friends, street sources)
O Never
O Seldom
O Sometimes
O Often
O Very Often
4. In the past 30 days, how often have you taken your medications differently from
how they are prescribed?
O Never
O Seldom
O Sometimes
O Often
O Very Often
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5. In the past 30 days, how often have you seriously thought about hurting yourself?
O Never
O Seldom
O Sometimes
O Often
O Very Often
6. In the past 30 days, how much of your time was spent thinking about opiod
medications (having enough, taking them, dosing schedule, etc.)?
O Never
O Seldom
O Sometimes
O Often
O Very Often
7. In the past 30 days, how often have you been in an argument?
O Never
O Seldom
O Sometimes
O Often
O Very Often
8. In the past 30 days, how often have you had trouble controlling your anger (e.g.,
road rage, screaming, etc.)?
O Never
O Seldom
O Sometimes
O Often
O Very Often
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9. In the past 30 days, how often have you needed to take pain medications
belonging to someone else?
O Never
O Seldom
O Sometimes
O Often
O Very Often
10. In the past 30 days, how often have you been worried about how you're handling
your medications?
O Never
O Seldom
O Sometimes
O Often
O Very Often
11. In the past 30 days, how often have others been worried about how you're
handling your medications?
O Never
O Seldom
O Sometimes
O Often
O Very Often
12. In the past 30 days, how often have had to make an emergency phone call or
show up at the clinic without an appointment?
O Never
O Seldom
O Sometimes
O Often
O Very Often 16
13. In the past 30 days, how often have you gotten angry at people?
O Never
O Seldom
O Sometimes
O Often
O Very Often
14. In the past 30 days, how often have you had to take more of your medication
than prescribed?
O Never
O Seldom
O Sometimes
O Often
O Very Often
15. In the past 30 days, how often have you borrowed pain medication from
someone else?
O Never
O Seldom
O Sometimes
O Often
O Very Often
16. In the past 30 days, how often have you used your pain medication for
symptoms other than for pain (e.g., to help you sleep, improve your mood, or relieve
stress)?
O Never
O Seldom
O Sometimes
O Often
O Very Often 17
1 7. In the past 30 days, how often have you had to visit the Emergency Room?
O Never
O Seldom
O Sometimes
O Often
O Very Often
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