Pain Relief Institute of America

New Patient Questionnaire

Description of Pain
8. How would you describe your pain?
9. Describe the timig of your pain
10. Does your pain radiate?
11. Have you had any surgeries related to your pain?
15. Does your pain interfere with any activities?
16. If so, then which one?
17. Do you currently or have you in the past 5 years seen a pain doctor?
19. Are you currently under a narcotic contract / opioid agreemen with another doctor or provider?
How have you treated your pain in the past & what was the result?
Acupuncture
What was the result?
Physical or Occupational Therapy
What was the result?
TENS
What was the result?
Chiropractic
What was the result?
Exercise
What was the result?
Masage Therapy
What was the result?
Epidural Steroid Injections / Medical Branch Blocks
What was the result?
Radiofrequency Albations
What was the result?
Trigger Point Injections
What was the result?
Spinal Cord Stimulation
What was the result?
Surgery
What was the result?
Medications
What was the result?
Do you take any blood thinners?
Are you allergic to contrasts?
Are you allergic to latex?
Do you have a pacemaker or implantable device?