Pain Self Evaluation & Intake Form Page 3
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1
2
3Have you had prior treatments for this?
I have not had any treatment for my current pain complaints
Type of treatment
When
Duration
No
Worse Mild
Moderately
Very
(m/yr)
of
help
helpful
helpful
helpful
treatment
Physical Therapy
Acupuncture/Massage
Chiropractor
Tens Unit
Psychological Therapy
MD name:
Spine surgery, Type of surgery:
Facet Injections
Level:
Rhizotomy
Level:
Epidural Steroid injections
Level:
Medial Branch Blocks
Level:
Spinal Cord Stimulator
Level:
Sacrioiliac injections
Level:
Vertebroplasty/Kyphoplasty
Level:
What medications do you currently take for your pain: please list all over the counter and prescription meds.
Medication
Dose
Frequency Started: m/yr
No help
Worse
Mild
Moderate
Very helpful
help
help
Are you taking any blood thinning medications:
Aspirin
Anti-inflammatory
Lovenox
Coumadin/Warfarin
Pletal
Aggrenox
Pradaxa
Ticlid
Plavix
Heparin
3
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