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Pain Relief Institute of America
New Patient Questionnaire
Description of Pain
1. Where is the majority of your pain?
2. When did this pain start?
3. How did this pain start?
4. What is your pain source today?
5. What is your AVERAGE pain source?
6. What makes your pain better?
8. What makes your pain worse?
8. How would you describe your pain?
Aching
Burning
Dull
Numbness
Pins & Needles
Sharp
Stabbing
Throbbing
Tingling
Other
9. Describe the timig of your pain
Constant
Increasing
Comes & Goes
Increasing
Decreasing
10. Does your pain radiate?
Yes
No
If so, where?
11. Have you had any surgeries related to your pain?
Yes
No
12. If so, when?
13. Type of surgery?
14. Are you involved in any pending litigation regarding this problem?
15. Does your pain interfere with any activities?
Yes
No
16. If so, then which one?
Bathing / Showering
Brooming
Driving
Preparing Meals / Cooking
Childcare
Housework
Sleeping
Sexual Activities
Exercising
17. Do you currently or have you in the past 5 years seen a pain doctor?
Yes
No
18. If so, when?
19. Are you currently under a narcotic contract / opioid agreemen with another doctor or provider?
Yes
No
How have you treated your pain in the past & what was the result?
Acupuncture
Yes
No
What was the result?
Improved
Worse
Physical or Occupational Therapy
Yes
No
What was the result?
Improved
Worse
TENS
Yes
No
What was the result?
Improved
Worse
Chiropractic
Yes
No
What was the result?
Improved
Worse
Exercise
Yes
No
What was the result?
Improved
Worse
Masage Therapy
Yes
No
What was the result?
Improved
Worse
Epidural Steroid Injections / Medical Branch Blocks
Yes
No
What was the result?
Improved
Worse
Radiofrequency Albations
Yes
No
What was the result?
Improved
Worse
Trigger Point Injections
Yes
No
What was the result?
Improved
Worse
Spinal Cord Stimulation
Yes
No
What was the result?
Improved
Worse
Surgery
Yes
No
What was the result?
Improved
Worse
Medications
Yes
No
What was the result?
Improved
Worse
Do you take any blood thinners?
Yes
No
Are you allergic to contrasts?
Yes
No
Are you allergic to latex?
Yes
No
Do you have a pacemaker or implantable device?
Yes
No
Your Signature
Clear
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