Is your pain the result of a:
Are you involved in litigation regarding this pain?
Have you ever been on disability?
What word best describes the frequency of your pain?
From 0-10 what best describes your pain right now?
From 0-10 what best describes your pain most of the time?
From 0-10 what best describes your worst pain?
From 0-10 what best describes your least pain?
Mark all of these diagnostic tests you have had related to your current pain complaints.
Mark all of the following pain treatments you have undergone prior to today’s visit:
Section II - Past Medical History
Section III - PAST SURGICAL HISTORY
Section IV - ALLERGIES:
Do you have any known drug allergies?
If so, please list all medications you are allergic to.
Please list ALL medications you are taking, with dosage and prescribing doctor's name.
Are you currently seeing a psychiatrist or psychologist?
Have you had any recent thoughts or ideations of suicide or harming others?
Do you take Street drugs?
Have you ever abused narcotic or prescription medications?