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PATIENT HISTORY QUESTIONNAIRE

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BALLARD WRIGHT, M.D., PSC
2416 REGENCY ROAD
LEXINGTON, KY 40503
PATIENT HISTORY QUESTIONNAIRE
Today’s Date:
Name:
Last
First
Middle
Social Security Number:
Date of Birth:
Mailing Address:
Phone Number:
Race:
White
Black/African American
American Indian/Alaska Native
Asian
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
If Primary Language is not English, please list:
I. DESCRIPTION OF YOUR PAIN
1. Where is your pain?
2. Is your pain the result of work injury or motor vehicle accident?
Yes
No
If Yes, Insurance Company:
Ins. Phone:
Date of Injury:
Claim Number:
3. On the diagram below, please indicate your pain (shade in all areas of the body where you feel pain).
(If filling this out digitally/online, you may skip this step)
BALLARD WRIGHT, M.D., PSC
Name:
Pain History Questionnaire -- Page 2
F:/FORMS/PREU 07-2019
4. How long have you had this pain?
Days:
Months:
Years:
5. How would you describe the duration of your pain?
It is constant and does not change.
It comes in separate attacks or episodes, and I am pain-free in between.
It is constant with periodic increases and decreases.
Other:
6. How would you describe your pain?
Aching
Crushing
Burning
Dull
Cramping
Throbbing
Sharp
Numb
Stabbing
Tingling
Shooting
Other:
7. Using the following scale, rate your pain by circling the number on the questions below:
0) Pain Free
1) Very minor annoyance; occasional minor twinges.
2) Minor annoyance; occasional strong twinges.
3) Annoying enough to be distracting.
4) Can be ignored if you are really involved in your
work, but still distracting.
5) Can’t be ignored for more than 30 minutes.
6) Can’t be ignored for any length of time, but you
can still go to work and participate in social
activities.
7) Makes it difficult to concentrate; interferes with
sleep. You can still function with effort.
8) Physical activity severely limited. You can read
and converse with effort. Nausea and dizziness set
in as factors of pain.
9) Unable to speak. Crying out or moaning
uncontrollably; near delirium.
10) Unconscious. Pain makes you pass out.
(Mankowski Pain Scale)
Your pain right now?
0
1
2
3
4
5
6
7
8
9
10
Your pain at its worst?
0
1
2
3
4
5
6
7
8
9
10
Your pain at its best?
0
1
2
3
4
5
6
7
8
9
10
Your pain most of the time?
0
1
2
3
4
5
6
7
8
9
10
8. What caused your pain?
9. What causes your pain to INCREASE?
10. What causes your pain to DECREASE?
11. What is your pain goal? (ex.: To be able to climb stairs, work in the garden, work, etc.)
12. Check/List any barriers you might have or anticipate concerning your ability to report pain or be treated for your pain
problem.
Difficulty understanding my pain problem.
BALLARD WRIGHT, M.D., PSC
Name:
Pain History Questionnaire -- Page 3
F:/FORMS/PREU 07-2019
Fear of what increased pain might mean (that I am getting worse/sick).
Previous side-effects/intolerances to medications/procedures.
Fear of addiction to medications.
Inability to get medications because they cost too much.
Transportation issues (don’t have a car, can’t drive, can’t afford gas, etc).
Difficulty understanding treatment plan because I do not understand English (well).
Other:
No anticipated concerns.
13. Have you ever been treated at a pain facility before?
Yes
No
If Yes, where:
when:
II. TREATMENT OF YOUR PAIN
1. What operations have you had for your Pain Problem?
DATE
OPERATION
SURGEON/WHERE
RESULT
No operations for pain problem.
2. What treatments have you had for your Pain Problem (injections, nerve blocks, chiropractic, exercise, massage,
braces, etc)?
DATE
TREATMENT
WHERE
RESULT
No treatments for pain problem.
3. Have you ever attended physical therapy for this pain problem?
Yes
No
If Yes, where:
when:
4. List diagnostic studies related to your Pain Problem (X-Rays, MRI, CT Scan, EMG/NCV, Bone scan, Myelogram,
etc)?
DATE
TEST
WHERE
RESULT
BALLARD WRIGHT, M.D., PSC
Name:
Pain History Questionnaire -- Page 4
F:/FORMS/PREU 07-2019
No diagnostic studies related to pain problem.
5. Please describe any drug allergies or bad reactions that you have had to medication.
MEDICATION
REACTION
No known drug allergies.
6. What medications are you currently taking for your Pain Problem?
M
EDICATION
DOSE
(mg)
N
O
.
OF
PILLS
T
IMES
PER DAY
HOW MUCH RELIEF YOU GET
0: None; 10: Complete
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
Currently not taking any medication for Pain Problem.
7. What other pain medications have you taken in the past?
MEDICATION
REASON FOR STOPPING MEDICATION
Have never taken any medication.
III. MEDICAL HISTORY
1. Have you had a different pain problem in the past (before your current problem)?
Yes
No
If Yes, please describe:
BALLARD WRIGHT, M.D., PSC
Name:
Pain History Questionnaire -- Page 5
F:/FORMS/PREU 07-2019
2. Check illnesses or conditions you have or have had in the past. Write in any not listed.
HEART & BLOOD VESSELS:
coronary artery disease
high cholesterol
theumatic fever
high blood pressure
heart attack(s)
irregular heart rhythm
neck artery blockage
congestive heart failure
heart valve problems
peripheral vascular disease
deep vein thrombosis
other:
SKIN:
rashes
eczema
psoriasis
cancer
other:
GLANDS:
diabetes mellitus
hypothyroidism
hyperthyroidism
pituitary
other:
STOMACH & DIGESTIVE SYSTEM:
hiatal hernia
acid reflux
ulcer
pancreatitis
poor appetite
liver disease
hepatitis
cancer
Crohn’s disease
obesity
irritable bowel syndrome
malnutrition
other:
URINARY SYSTEM:
kidney stones
urinary tract infection
kidney failure
cancer
other:
FEMALE ORGANS:
ovarian cysts
endometriosis
ovarian/uterine/cervical/breast cancer
other:
MALE ORGANS:
enlarged prostate
prostate/testicular cancer
other:
EYES:
cataracts
injury
glaucoma
vision loss/difficulty
other:
EARS, NOSE, THROAT:
sinus/allergy problems
hearing loss
inner ear disease
dentures
TMJ disease
speech difficulty
other:
BLOOD:
anemia
bleeding easily
blood clots
lymphoma
chemotherapy
other:
ALLERGY/IMMUNE:
lupus
rheumatoid arthritis
fibromyalgia
HIV
other:
MUSCULOSKELETAL:
osteoarthritis
broken bone
rotator cuff disease
carpal tunnel syndrome
scoliosis
osteoporosis
degenerative disc disease
degenerative joint
other:
NEUROLOGICAL:
headache
migraine
seizure
epilepsy
stroke
tumor
meningitis
head injury
blackouts
multiple sclerosis
organic brain disease
confusion
memory loss
other:
LUNGS:
asthma
emphysema
cancer
bronchitis
tuberculosis
COPD
black lung
sleep apnea
other:
P
SYCHIATRIC
:
depression
anxiety/panic
bipolar disease
schizophrenia
PTSD
other:
3. Have you ever seen a psychologist, psychiatrist, or other mental health counselor?
No.
Yes, in the past.
When?
Yes, currently.
Who?
If Yes, what problems were you seen for?
BALLARD WRIGHT, M.D., PSC
Name:
Pain History Questionnaire -- Page 6
F:/FORMS/PREU 07-2019
4. List all surgeries you have had (except those listed previously relating to your Pain Problem)?
DATE
OPERATION
SURGEON/WHERE
No previous surgeries (unrelated to pain problem).
5. Family History:
State of Health or Cause of Death
Is your mother
Living:
Deceased:
Is your father
Living:
Deceased:
How many brothers
Living:
Deceased:
How many sisters
Living:
Deceased:
IV. SOCIAL HISTORY
1. What is your current marital status?
Single
Married
Separated
Divorced
Widowed
2. Do you have any relatives who are, or have been patients at The Pain Treatment Center?
Yes
No
If Yes, who/relation:
3. With whom do you currently live?
Spouse
Children, #
Parents
In-laws
Other relatives
Friends
Alone
Other:
4. How many years of school did you complete?
5. What is your present work situation? (check and provide details, if needed)
Disabled:
Temporary
Permanent
Date declared disabled:
Physician or court that declared you disabled?
Employed full-time. What kind of work?
Employed part-time/Light duty. What kind of work?
(continued on next page…)
Homemaker.
Inactive homemaker because of pain.
Unemployed for other reasons. Why?
In school or vocational training. Where?
Retired. Occupation prior to retiring?
6. If you are currently not working, when did you last work?
What kind of work did you do at that time?
BALLARD WRIGHT, M.D., PSC
Name:
Pain History Questionnaire -- Page 7
F:/FORMS/PREU 07-2019
7. How many cups of coffee, tea, or soft drinks with caffeine do you drink daily?
8. Do you smoke cigarettes?
Yes
No
If Yes, how many packs per day?
How many years have you smoked cigarettes?
9. How often do you drink alcohol?
Not at all
1-2 times per week
Less than once a month
2-4 times per week
1-2 times per month
Everyday
What effect does alcohol have on your pain?
10. Have you use illegal drugs in the past (marijuana, cocaine, amphetamines)?
Yes
No
Illegal drug used?
Date last used:
11. Have you been diagnosed or treated for substance abuse problems (alcoholism, drug addiction, etc)?
Yes
No
If Yes, when and where?
12. Have you ever been arrested for an alcohol or drug-related offense (DUI, public intoxication,
possession, diversion, trafficking, etc)?
Yes
No
If Yes, what was the offense?
Date of the arrest:
13. Have you ever been arrested for any other reason?
Yes
No
If Yes, explain:
Date of the arrest:
BALLARD WRIGHT, M.D., PSC
Name:
Pain History Questionnaire -- Page 8
F:/FORMS/PREU 07-2019
V. EFFECT OF PAIN ON LIFESTYLE
1. Check one number that best describes your normal day-to-day activity:
0) Stay in bed all day. Feel hopeless and helpless about life.
1) Stay in bed at least half the day. Have no contact with outside world.
2) Get out of bed, but don’t get dressed. Stay at home all day.
3) Get dressed in the morning. Minimal activities at home. Contact with friends via phone, email.
4) Do simple chores around the house. Minimal activities outside of home, two days a week.
5) Struggle, but fulfill daily home responsibilities. No outside activity. Not able to work/volunteer.
6) Work/volunteer limited hours. Take part in limited social activities on weekends.
7) Work/volunteer for a few hours daily. Can be active at least five hours a day. Can make plans to do simple
activities on weekends.
8) Work/volunteer for at least six hours daily. Have energy to make plans for one evening of social activity during
the week. Active on weekends.
9) Work/volunteer/be active eight hours daily. Take part in family life. Outside social activities limited.
10) Go to work/volunteer each day. Normal daily activities each day. Have a social life outside of work. Take an
active part in family life.
(Quality of Life Scale, American Chronic Pain Association)
2. How has your pain changed your activity level?
Not at all
Slightly
Moderately
Significantly
Severely
Is your activity level affected by anything other than pain?
Yes
No
If Yes, please explain:
How far can you walk before you have to stop because of pain?
How long can you stand before you have to stop because of pain?
How long can you sit before you have to get up because of pain?
3. Does your pain problem affect your ability to concentrate?
Always
Rarely
Usually
Never
Sometimes
4. How many hours of sleep do you actually get each night?
hours.
How many hour do you spend trying to get to sleep (lie in bed)?
hours.
5. How long does it take you to get to sleep once lying down?
BALLARD WRIGHT, M.D., PSC
Name:
Pain History Questionnaire -- Page 9
F:/FORMS/PREU 07-2019
6. How often does pain interfere with your sleep?
Always
Rarely
Usually
Never
Sometimes
7. What sort of sleep problems do you have?
No problems with sleep
Awaken too early in the morning
Takes a long time getting to sleep
Awaken unrested and exhausted
Awaken frequently during night
Frequent napping during the day
Fitful and disturbed sleep
Daytime fatigue from poor sleep
Nightmares
Other:
8. Please use the following scale to evaluate your sleepiness:
0) Would never doze
1) Slight chance of dozing
2) Moderate chance of dozing
3) High chance of dozing
(Epworth Scale)
Circle the number
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sitting inactive in a public place (theater or a meeting)
0
1
2
3
As a passenger in a car for an hour without a break
0
1
2
3
Lying down to rest in the afternoon when circumstances permit
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after lunch without alcohol
0
1
2
3
In a car, while stopped for a few minutes in traffic
0
1
2
3
9. Have you ever had a sleep study?
Yes
No
If Yes, what were the results of the study:
Thank you for taking the time to complete this questionnaire.
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Completed 22 July 2021

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