Allevio pre-assessment questionnaire Allevio Healthcare Inc. November 2015
INDEPENDANT MEDICAL EVALUATION (IME) QUESTIONNAIRE:
You have been referred by your lawyer or insurer for an independent medical assessment regarding the pain you have. Your assessor will be a licensed physician with a special interest in chronic pain management. Please complete this form and return by fax to (647) 427-4100 at least 1 week before your scheduled appointment. Your privacy is a priority – this information will remain confidential within our medical files.
TODAY’S DATE: _________________ NAME: _________________________________________________ Year/Month/Day First Middle Last
DATE OF ACCIDENT: ________________ DATE OF BIRTH: ____________________ Age: _____ Year/Month/Day Year/Month/Day
SEX: HEIGHT: _______ WEIGHT: ______ HANDED:
PLACE OF BIRTH: _____________ Year you immigrated to Canada: ____ LANGUAGE SPOKEN: ______________
TELEPHONE: __________________________________________________ EMAIL: _____________________ Home Work Cellular
DESCRIPTION OF INJURY/ACCIDENT: 1. Please describe the current injury:
a. What type of injury was this? Car accident Work Accident Slip and Fall
Other (describe, and clarify if there are more than one accidents to discuss):
b. What type of vehicle were you in? _____________________c. You were the:
d. Were you wearing a seatbelt?
e. Did the airbags open?
f. Did you lose consciousness?
g. Did you have pain immediately?
Male Female Le ft Right
Driver Passenger, front Passenger, back
No Yes
No Yes
No Yes Not Sure
No; when did it start? _________________________
Yes, where in the body?_______________________________
______________________________________________________
h. Who attended the scene? Polic e Param edic s N o one else
i. When did you first seek medical attention? __________________________
j. When did you first start physical therapy? ___________________________
1. Do you currently attend? Yes , How often? __________________ No
2. Circle one number to indicate how helpful you find physical therapy?
0 1 2 3 4 5 6 7 8 9Not at all
10 All of the time
Allevio pre-assessment questionnaire Allevio Healthcare Inc. November 2015
k. List the medical tests and consultations (with approximate dates) you have had since the accident:
2. Since the accident, your overall pain has: increased decreased not changed fluctuated
3. Since the accident, your overall condition has:
4. Overall, to what extent do you feel the pain has interfered with your life?
0 1 2 3 4 5 6 7 8 9 10 Not at all Extreme interference
MEDICAL INFORMATION:
5. Have you been in any previous accidents or major injuries? N o Y e s , p l e a s e d e s c r i b e :
6. Family Doctor:
a. Before the accident: ____________________________________________________________
b. Now: ____________________________________________________________
c. If different, what is the reason for a change? ____________________________________________
increased decreased not changed fluctuated
7. Please check off and specify any major illnesses or surgeries you have had, and explain if they began
before or after the accident:
Illness/Surgery Yes No
Cancer in past 5 years
Smoking
Alcohol
Depression
Anxiety
Trauma
Mood Disorder
Psychiatric Illness
Addiction
Heart Attack/CHF
Heart Surgery
Before Accident SpecificationAfter
Accident
Illness/Surgery Yes No
Hypertension
Before Accident
SpecificationAfter Accident
Pacemaker or ICD
Sleep Apnea
COPD
Kidney Failure
Cirrhosis
Hepatitis B or C
HIV
Blood Disorder
Epilepsy/Seizures
Neuropathy
Rheumatoid Arthritis
Osteoarthritis
Joint Replacement
Spinal Surgery
Other:
Allevio pre-assessment questionnaire Allevio Healthcare Inc. November 2015
Any additional information:
Allevio Healthcare Inc. November 2015 Allevio pre-assessment questionnaire
Name Dose TAKEN Times taken per day For what condition?
9. Allergies to medication:
8. List ALL medications you are currently taking (may attach list):
_______________________________________________________________________________________
SOCIAL HISTORY:
10. Where were you born? ____________________
11. Highest level of education attained? _________________
12. Type of degree: ________________
13. Total years of post-secondary education attended? _________________
14. Do you live in a:
a. Rental apartment
b. Rental town home
c. Own house
d. With your parents
e. Other
i. Please specify: ________________
15. Please describe if your living situation has changed since the accident: _____________________________
__________________________________________________________________________________________
Allevio pre-assessment questionnaire Allevio Healthcare Inc. November 2015
16. Please describe your marital status?
separated for ____ year s divorced for ____ year s
a. Please describe how, if at all, your relationship has changed since the accident: ________________
____________________________________________________________________________________
b. How would you rate your relationship with your partner BEFORE the accident? Please circle the
number:
1 2 3 4 5 6 7 8 9 10 Poor Excellent
c. How would you rate your relationship with your partner NOW?
1 2 3 4 5 6 7 8 9 10 Poor Excellent
17. How many children do you have? __________ Ages? __________
a. To what extent has your ability to parent your children changed since the accident?
4 5 6 7 8 9 1 2 3 No interference
10 Extreme interference
b. Please describe how, if at all, your relationship with your children has changed since the accident:
single m arried for ____ years
in a s t a b l e r e l a t i o n s h i p for ____ years widowed
18. Prior to the accident, how did you like to spend your free time when not working? What hobbies or
recreational activities did you enjoy? Please be specific, including time spent each day or week.
a. Please describe how, if at all, these activities have changed since the accident:
Allevio Healthcare Inc. November 2015
19. Describe your typical day in the past few weeks:
n o t c h a n g e d i n c re a s e d d e c re a s e d , b y ___________ l b s
FUNCTIONAL STATUS:
20. Since the accident, your weight has:
21. Please describe your sleeping patterns:
Prior to injury After injury for 1 month Currently
Minutes to fall asleep
Hours per night, total
Times woken up
Restful or not restful
Hours resting during day
Nightmares about
accident
Nightmares about other
a. Your sleeping patterns are:
MENTAL HEALTH STATUS: 22. Please describe your mood and related symptoms:
improving getting worse stable for past month
Allevio pre-assessment questionnaire
Degree of improvement
Happy
Balanced
Energetic
Sad
Depressed
Worried
Anxious
Angry
Irritable
Fatigued
Getting WorseUnchanged in past months Improving
Allevio Healthcare Inc. November 2015 Allevio pre-assessment questionnaire
Yes N o a. Have you attending counselling since the accident?
1. If yes:
1. For how long? ____________
2. With who? _______________
How often? ____________ 3. Are you still attending?
4. Did you find it helpful?
Yes No
Ye s N o Unsure
Degree of improvement
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Despairing
Unable to concentrate
Unable to cope
Want to be with people
Want to be alone
Getting WorseUnchanged in past months Improving
Other (please specify): ___________________
b. Describe other types of treatment or programs have you attended related to your mood since the
accident:
Allevio pre-assessment questionnaire Allevio Healthcare Inc. November 2015
ACTIVITIES OF DAILY LIVING:
23. In terms of self-care activities, such as dressing, bathing and grooming:
I was fully capable and
independent with:
I needed some help with: I was unable to do the
following:
Prior to the accident:
After the accident:
Currently:
24. Please check off the box that best describes how difficult it has been to do each of the following in the past
few weeks?
Degree of difficulty None Slight Moderate Extreme Can’t do
Dress yourself
Shampoo/style hair
Get on and off toilet
Get in and out of bed
Walk outdoors on flat ground
Climb up 5 steps
Bend and pick-up clothing from floor
Get in and out of a car
Make meals
Degree of independance Able to do on your own
Require full assistance
Dust
Vacuum
Bathroom
Mopping
Dishes
Cooking
Folding Laundry
Lifting Laundry
Carrying Groceries
Lawn Care
Gardening
Shoveling
Able to do on your own
Require full assistance
Prior to Accident Currently
25. Please check off the box that best describes your degree of independence prior and after the accident:
OCCUPATIONAL HISTORY: N o Y e s, h o u r s p e r w e e k : ________________
N o
26. Were you working prior to the accident?
a. Occupation?________________________
27. Are you currently working?
28. Is it the same job as before the accident? N o
a. If no, please describe your job situation since the accident in detail:
Y e s , h o u r s p e r w e e k :________________
Y e s,
Allevio Healthcare Inc. November 2015 Allevio pre-assessment questionnaire
Allevio Healthcare Inc. November 2015 Allevio pre-assessment questionnaire
30. Have you required additional sick leave or time off for treatment since the accident?
a. On average, how many sick days did you take per 6 months before the accident?
b. On average, how many sick days do you take per 6 months over the past year?
No Yes
____________
_____________
Heavy Lifting
Light Lifting
Bending
Sitting
Twisting
Reaching Up
Typing
Concentration
Customer Service
Calculations
Quick Thinking
Other:
Job Prior to Accident Current Job (if different)
29. What are the physical and mental demands of your prior or current job?
31. Please describe how, if at all, your current condition affects your ability to perform your work:
Allevio pre-assessment questionnaire Allevio Healthcare Inc. November 2015
32. Pain Levels:
a. Circle one number to indicate how much of the time you were in pain during the past 4 weeks:
0 1 2 3 4 5 6 7 8 9 10 Not at all All of the time
b. Please rate your worst pain over the past 4 weeks:
0 1 2 3 4 5 6 7 8 9 10 No Pain Worst pain imaginable
c. Please rate your least pain over the past 4 weeks:
0 1 2 3 4 5 6 7 8 9 10 No Pain Worst pain imaginable
d. Please rate your average pain over the past 4 weeks:
0 1 2 3 4 5 6 7 8 9 10 No Pain Worst pain imaginable
33. Location of CURRENT pain: Please mark an “X” on the area(s) where you feel pain on these drawings:
List the painful sites from worst pain to least pain: _______ >________ > _______ > _______ > _______
Allevio Healthcare Inc. November 2015
34. Quality of pain: List each of the areas of your pain in the table below and place an “X” beside each
of the words that best describe your pain.
List the Pain Location:
a. b. c. d. e.
Constant
Comes and goes
Sharp
Shooting
Stabbing
Throbbing
Aching
Tight
Burning
Cramping
Other:
Other:
If more than 5 pain sites, please describe:
Allevio pre-assessment questionnaire
Worst Pain Least Pain
35. Which of the following symptoms do you experience? (Check only the ones that apply)a. Bowel Incontinence (soiling yourself)
b. Urinary Incontinence (wetting yourself)
c. Night Sweats
d. Unintended Weight Loss
e. Weakness resulting in falls or dropping things
f. Numbness pins/needles tingling
right left
I. Where? ___________________
i. Shooting pain down the arm(s); which one?
ii. Shooting pain down the leg(s); which one? right left
Allevio pre-assessment questionnaire Allevio Healthcare Inc. November 2015
36. Describe everything that aggravates your pain, for each of the sites listed above (in same order):
37. Check off everything that relieves your pain, even mildly or temporarily:
restmedication sleep exercise
relaxation injections swimming
bending stretching physical therapy
other: __________________________________
List the Pain Location:
a. b. c. d. e.
Lifting
Bending
Walking
Standing
Sitting
Climbing Stairs
Couging
Sneezing
Looking Up
Looking Down
Turning the Head:
Reading:
Thinking
Stress
After Sleep
Other:
If more than 5 pain sites, please describe:
Allevio pre-assessment questionnaire Allevio Healthcare Inc. November 2015
Pain Disability Questionnaire (PDQ)
Patient Name: ________________________________________ Date:______________________________
Instructions: These questions ask your views about how your pain now affects how you function in everyday
activities. Please answer every question and circle the ONE whole number on EACH scale that best describes
how you feel.
1. Does your pain interfere with your normal work inside and outside the home?
Work normally Unable to work at all 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
2. Does your pain interfere with personal care (such as washing, dressing, etc)?
Take care of myself completely Need help with all personal care 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
3. Does your pain interfere with your traveling?
Travel anywhere I like Only travel to see doctors 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
4. Does your pain affect your ability to sit or stand?
No problems Cannot sit/stand at all 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things?
No problems Cannot do at all 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat?
No problems Cannot do at all 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
7. Does your pain affect your ability to walk or run?
No problems Cannot walk or run at all 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
Allevio pre-assessment questionnaire Allevio Healthcare Inc. November 2015
8. Has your income declined since your pain began?
No declineLost all income
0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
9. Do you have to take pain medication every day to control your pain?No medication needed On pain medication throughout the day 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
10. Does your pain force you to see doctors much more often than before your pain began?
Never see doctors See doctors weekly 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
11. Does your pain interfere with your ability to see people who are important to you as much as you would like?
No problem Neversee them0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
12. Does your pain interfere with recreational activities and hobbies that are important to you?
No interference Total interference 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
13. Do you need the help of your family and friends to complete everyday tasks (including both work outside the
home and housework) because of your pain?
Never need help Need help allthe time0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
14. Do you now feel more depressed, tense, or anxious than before your pain began?
Severe No depression/tension0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
15. Are these emotional problems caused by your pain that interfere with your family, social and/or work
activities?
No problems 0 ---------- 1 ---------- 2 ---------- 3 ---------- 4 ---------- 5 ---------- 6 ---------- 7 --------- 8 ---------- 9 --------- 10
Thank you for taking the time to complete this and return to us.
Severe problems