Welcome to Pain Management Institute

To make an appointment for any of our locations, please call
  (815) 464-7212

Patient Intake Form

Section I - Patient Information

Patient Name

Patient Email

Date of Birth

Age

Gender

Approximately when did this pain begin

Is your pain the result of a:

Are you involved in litigation regarding this pain?

Have you ever been on disability?

Are you working now?

Last date of work?

What kind of work do you do?

Check all of the following that best describes your pain:
 Aching Hot/Burning Shooting Stabbing/Sharp Cramping Numbness Spasming Throbbing Dull Shock-Like Squeezing Tiring/Exhausting Tingling/Ping and Needles

Other

What word best describes the frequency of your pain?

When is your pain at its worst?
 Mornings During the day Evening Middle of the night

Other

How long can you walk until you must stop due to pain?

What activities is the pain preventing you from doing?

My Pain is improved by

List Doctors you have seen & City:

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.

Date:

Facility:

Date:

Facility:

Date:

Facility:

Date:

Facility:

Mark all of the following pain treatments you have undergone prior to today’s visit:

 Chiropractic Physical Therapy Massage Acupuncture Spine Surgery Psychological Therapy Spasming

Discogram –(Circle all levels that apply)

 Cervical Thoracic Lumbar

Epidural Steriod Injection –(Circle all levels that apply)

 Cervical Thoracic Lumbar Joint Injections – Joint(s)

Medical Branch Blocks or Facet Injections –(Circle all levels that apply)

 Thoracic Lumbar Joint Injections – Joint(s)

Radiofrequency Ablation –(Circle all levels that apply)

 Thoracic Lumbar Joint Injections – Joint(s)

Spinal Stimulator - (Circle one)" "Trial Only" "Permanent Implant

 Trigger Point Injection – Where?

 Vertebroplasty / Kyphoplasty – Level(s)?

Other

Section II - Past Medical History

Heart Murmur

Shortness of breath

Gastritis or ulcers

Palpitations

Bronchitis

Hital Hernia

Heart Attack

TB

Thyroid Disease

Stroke

Asthma

Diabetes

Irregular Heart Beat

Emphysema

Kidney Problems

High Blood Pressure

Sleep Disturbance

Liver Disease

Angina (Chest Pain)

Sleep Apnea

Difficulty Urinating

Seizures

Migraine Headaches

Hepatitis

Arthritis

Weight Change

HIV or exposure

Cancer

Other

Section III - PAST SURGICAL HISTORY

Name:

Date:

Name:

Date:

Name:

Date:

Name:

Date:

Name:

Date:

Section IV - ALLERGIES:

Do you have any known drug allergies?

If so, please list all medications you are allergic to.

Medication Name:

Allergic Reaction Type:

Medication Name:

Allergic Reaction Type:

Medication Name:

Allergic Reaction Type:

Are you allergic to
 Iodine Latex Tape Shellfish Eggs Sulfa

Current Medications:

Please list ALL medications you are taking, with dosage and prescribing doctor's name.

Medication Name:

Dose Strength:

Medication Name:

Dose Strength:

Medication Name:

Dose Strength:

PSYCHIATRIC HISTORY

Are you currently seeing a psychiatrist or psychologist?

If yes, Whom?

Have you had any recent thoughts or ideations of suicide or harming others?

SOCIAL HISTORY

What is your occupation:

What is your occupation:

Do you smoke?

If yes, what and how much?

Do you drink alcohol?

If yes, what and how much?

Do you take Street drugs?

If yes, what and how much?

Have you ever abused narcotic or prescription medications?

If yes, what ?

 I agree to the follwoing terms and conditions