Pain Assessment Form - Pain Management Specialists Of Baytown
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1ADVANCED PAIN MANAGEMENT SPECIALISTS
PAIN ASSESSMENT FORM
CC: Med Management
Patient name:___________________________________________DOB:________________________________ Today’s date:______________________
F/U Procedure
Pump Refill
New Patient
Please complete the following questionnaire. Provide complete information to all questions that apply to you. If you have
questions, please ask for assistance.
Recent pain block injection
_____ Yes _____ No
PAIN HISTORY:
Procedure name:
___________________________________
Where is your pain located? Check all that apply. Circle side Left (L), Right (R), or Middle (M)
#________ of _________
Date:_____________________________
__ Low back L M R __Mid back L M R ___Upper back L M R __Neck L M R __Chest L M R
% Improvement ________________
__ Abdomen L M R __ Buttock L M R __ Thigh L M R __Calf L M R __Ankle L M R
__Foot L M R __ Head L M R __ Face L M R __ Shoulder L M R __Arm L M R __Hand L M R
Weight:__________________________
B/P:_____________ Pulse:________
Does it radiate? If yes, where? _______________________________________________________________________________________________________
What do you think caused your pain?________________________________________________________________________________________________
When do you experience the most pain? Morning Afternoon Evening Night
What aggravates your pain? __Standing __Sitting __Bending __Walking __ Other:_____________________________________________
What relieves your pain? __Lying down __Sitting __Physical therapy __Meds __Ice __Heat __TENS __Steroid Injection
__Behavioral therapy ___Other:_______________________________________________________________________________________________________
Would you describe your pain as:
Dull aching:
yes
no
Burning:
yes
no
Throbbing:
yes
no
Sharp:
yes
no
Shooting:
yes
no
Other:________________________________________________________________________
How well do you sleep?____________________________________________________
Do you have?
Numbness:
yes
no
Where?_________________________________________
Tingling:
yes
no
Where? _________________________________________
Weaknesses:
yes
no
Where? _________________________________________
Coldness:
yes
no
Where?__________________________________________
Increased sweating:
yes
no
Where?__________________________________________
Muscle spasm/cramp:
yes
no
Where?__________________________________________
Skin color / other change:
yes
no
Where?__________________________________________
On a scale of 0‐10 (0 is no pain, and 10 is the worse possible pain)
How is your pain now?___________ How is your pain at its worse?____________ How is your pain at its least?__________
How much pain do you have on average?_____________
Allergies to medications? Yes No List medications and reactions______________________________________________________
___________________________________________________________________________________________________________________________________________
List ALL medications you currently take:
Medication
Strength
#Pills taken #times/day
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
List previously prescribed PAIN medications:_______________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
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Parent category: Medical