Utah Pain Specialists

Utah Pain Doctors | 801-685-PAIN (685-7246)

Tuesday - Friday, 8 AM - 6 PM

PATIENT FORMS

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NEW PATIENT QUESTIONNAIRE

Welcome

Step 1 of 9

Welcome to our online New Patient Questionnaire. We need to gather as much information as possible regarding you and your symptoms in order to begin the process of developing a treatment program tailored just for you.

The questionnaire is quite thorough and may take several minutes to complete. Please allow yourself enough time to complete the requested information in one session. Because we value your privacy, all information provided is sent directly to treatment specialists and not stored. If you are unable to complete the questionnaire in a single session, it will be necessary for you to start over at a later time.

Patient Information

Patient Name First: Middle: Last:

Mailing Address:

Physical Address:

Same as mailing address

Street:

City:

State:

Zip:

State:

Zip:

Date of Birth::

(mm/dd/yyyy)

Email:

Home Phone:

(xxx)xxx-xxxx

Referring Physician:

Phone:

Primary Care Physician:

Phone:

Emergency Contact:

Phone:

Your Insurance:

Phone:

Section 1: History of Present Illness

Step 2 of 9

As best as you understand, why did your referring physician send you to our clinic?

Are you involved in any court cases or lawsuits? Yes No

Do you have a Workers' Compensation claim? yes no

Describe your pain. (mark all that apply)

Dull	Achy	Depressing	Sharp	Cruel	Throbbing
Stabbing	Shooting	Tingling	Numb	Burning	Pins and Needles
Splitting	Pressure	Ripping	Punishing	Stressful	Unbearable
Fearful	Crushing	Sad	Tearful	Squeezing	Uncontrollable

Where do you hurt? (mark all that apply)

Low back	Abdomen	Leg	Neck
Foot	Hip	Hand or Fingers	Shoulder
Headaches	Wrist	Mid back	Pelvic Pain
Chest Wall	Buttocks	Knee	I hurt Everywhere
Other:

Section 1: History of Present Illness (continued)

Step 3 of 9

My pain is Continuous with no flares Continuous with flares Intermittent with flares

When did your pain start?

Was there an event that started your pain? Yes No

List activities that worsen the pain:

List activities that improve the pain:

Section 2: Sleep

Step 4 of 9

How many total hours of sleep time each night?

How many times do you awaken due to pain?

Section 3: Mood

During the past month, have you felt down, blue, depressed or hopeless due to pain? Yes No

Have you ever felt like harming yourself? Yes No

Have you ever felt like harming anyone else? Yes No

Have you ever had a suicide attempt? Yes No

Do you ever have panic attacks? Yes No

Section 4: Function

Step 5 of 9

Mark regular activities you cannot do because of pain. mark all that apply.

Bending	Exercising	Lifting	Sitting
Walking	Standing	Gardening	Housework
Other:

Are you working?

Yes No

Section 5: Allergies

Please indicate if you are allergic to any of the following:

Latex Iodine Medical Adhesives (tapes, band-aids, etc) Antibiotics (Neosporin, Penicillin, etc)

Have you ever been told you have a severe allergy to a medicine?

Yes No

Section 6: Medications

Step 6 of 9

Please list all current medications and doses:

do you take any blood thinners such as coumadin, plavix, or lovenox?

Yes No

do you take any over-the-counter medicines containing tylenol or acetaminophen?

Yes No

section 7: other medical problems

list other medical problems (eg. high blood pressure, diabetes, asthma, etc.)

Section 8: Surgical History

Step 7 of 9

list past surgeries and the dates they were performed.

surgery	Date (mm/dd/yy)
1.
2.
3.
4.
5.
6.

Please list any previous pain injections/procedures tried in the past.

injection/procedure	Date	Injection/Procedure	Date (mm/dd/yy)
1.		2.
3.		4.

Section 9: Family History

List any medical problems that run in your family.

Section 10: Other Treatments

Step 8 of 9

Please indicate all other therapies used to relieve your pain:

Physical Therapy	Massage Therapy	Chiropractic Acupunture
Epidural Injection	Radio Frequency Rhizotomy	Other Shot
Other:

Section 11: Social History

Do you currently use tobacco? Yes No

Do you drink alcohol? Yes No

Have you used steet drugs in the past year? Yes No

Have you ever finished a prescription medication earlier than was prescribed or received the same medication from multiple physicians? Yes No

Marital status: Married Divorced Single Widow

Do you have children? Yes No

Section 12: General health questionnaire

Step 9 of 9

General:		Fever Chills Night sweats Excessive fatigue Weight loss Weakness
Eyes:		Change in your vision Eye pain Eye swelling Tearing
Ears:		Hearing loss Ringing in the ears Ear pain Discharge
Nose:		Nose bleeds Discharge Stuffy nose Sinus problems Loss of Smell
Throat:		Sore throat Change in taste Discharge Bad breath Dental Cavities
Neck:		Stiff neck Neck pain Whiplash injury
Heart:		Chest Wall Pain Swollen Ankles Exercise intolerance Fainting
Lungs:		Cough Wheezing Emphysema Bronchitis Coughing up blood
Gastrointestinal:		Diarrhea Constipation Abdominal pain Heartburn Jaundice Hepatitis Blood in stools Black tarry stools Hernia Bowel Incontinence
Urinary:		Burning Frequency Urgency Stress-incontinence Kidney stones
Musculoskeletal:		Stiff joints Arthritis Restless legs at night Muscle spasms Scoliosis
Skin:		Rash Eczema Dry Skin Itching
Neurological:		Numbness Tingling Weakness Tripping Falling Headaches
Psychiatric:		Claustrophobia Paranoia Nightmares Hearing voices
Blood:		Bleed easily Bruise easily Using a blood thinner
Other comments:

Yes	No		Yes	No
		Numbness in the arms or legs			Daytime somnolence (feeling very sleepy during the day)
		Tingling in the arms or legs			Morning headaches
		Weakness in the arms or legs			Night sweats
		Bladder incontinence (being unable to control your bladder or accidentally wetting yourself)			Heartburn or a sour taste in your mouth a night
		Bowel incontinence (being unable to control your bowels or accidentally soiling yourself)			Periods when you stop breathing
		Snoring

No Pain At All									Worst Pain
0	1	2	3	4	5	6	7	8	9	10

No Pain At All									Worst Pain
0	1	2	3	4	5	6	7	8	9	10