Quadrahealth.com

New Patien
Patien t Qu
What is your main reason for seeing us today?
Previous Diagnosis:
Have you received a diagnosis from a previous pain specialist? Did he/ she explain the cause or reason for the pain you're feeling? Was your Injury on the job/ auto accident/ fall/ spontaneous occurance/ sports injury/ other: Is the pain constant/ intermittent/ sporadic/ worse at night/ worse in the morning/ other: Your best position is: lying on back/ lying on stomach/ lying on side/ sitting/ standing/ reclining/ none/ other: Your worst position is: lying on back/ lying on stomach/ lying on side/ sitting/ standing/ reclining/ other: Modifying Factors:
Is the pain worsened by: lifting/ bending/ sitting/ playing with children/ walking/ driving/ sports activities/ socializing/ The Pain is relieved by: rest/ changing positions/ medications/ heat/ ice/ exercise/ distraction/ relaxation strategies/ Motor Vehicle Accident Details: (Complete only if in motor vehicle accident)
Auto Accident: Type of accident/ head on/ t-boned/ rear ended/ sandwiched/ roll over/ other: If passenger, were you in the front seat/ back seat/ right/ left/ or middle seat Did you/ and/ or the other driver receive a ticket? Immediate Care: (Complete for Worker's Comp, Motor Vehicle Accident or other injury)
Taken by ambulance to emergency room.
You went to your primary care physican ______ days later. Did you experience pain in a different area after the accident? If so, where and how many days, weeks or months Functional Limitations:
Are you having difficulty with any of the following activities: playing with children/ walking/ sitting/ bending/ lifting/ working/ driving/ sports activities/ socializing/ standing/ household chores/ other: Are you having any bowel problems such as: uncontrollable bowel/ constipation/ irritable bowel syndrome/ other: Are you having any problems with your bladder such as: urinary frequency/ urinary incontinence/ Sexual Dysfunction:
Males: Are you having erectile dysfunction: difficulty achieving erection/ difficulty maintaining erection/
Females: Difficulty achieving orgasm/ painful intercourse/ other:
Treatments Tried to Date:
Physical therapy: Yes/ No Provided relief/ provided no relief/ made pain worse.
Chiropractic Manipulation: Yes/ No Provided relief/ provided no relief/ made pain worse.
Acupuncture: Yes/ No Provided relief/ provided no relief/ made pain worse.
Massage therapy: Yes/ No Provided relief/ provided no relief/ made pain worse.
Injections: Yes/ No Location: Back/ Neck/ Joint, If tendon, which one? ____________
If injections have been received which of these have you had: Facet blocks/ epidural injection/ SNRB/ TFE/ SI joint/
DIL/ trigger point injection/ bursal injection/ joint injection/ tendon injection/ unknown type/ other: Exercise: Yes/ No Home exercise program ____ days per week, gym program _____ days per week
Medications Tried:
Narcotic Analgesics: Actiq/ Avinza/ Butrans/ Demerol/ Dilaudid/ Duragesic Patch/ Exalgo/ Hydrocodone/
Hydrocodone/ APAP/ Kadian/ Methadone/ MS Contin/ MSIR (Morphine Sulfate Immediate Release)/ MSER (Morphine Sulfate Extended Release)/ Opana IR/ Opana ER/ Oxycodone/ Oxocodone APAP/ OxyContin/ Oxyfast/ Tylenol 3/ Ultram/ other: Anti-Inflammatories: Celebrex/ DayPro/ Etodolac/ Ibuprofen/ Mobic/ Naprosyn/ Prednisone/ Relafen/ other:
Muscle Relaxants: Amrix/ Baclofen/ Flexeril-Zanaflex/ Norflex/ Robaxin-Methocarbamol/ Skelaxin/ Soma-Carisaprodol
Benzodiazepines: Clonazepam/ Lorazepam/ Valium/ Xanax-Alprazolam/ other:
Antidepressants: Amitriptyline/ Buspirone/ Cymbalta/ Desipramine/ Effexor/ Lexapro/ Nortriptyline/ Paxil/
Pristique/ Trazodone/ Viibryd/ Zoloft/ other: Anti-Seizure Medications: Keppra/ Neurontin/ Topomax/ Trileptil/ Valproic Acid/ Zonegran/ other:
Diagnostics: Please bring the following studies with you to your New Patient Evaluation
Lab Tests: (blood draw) Lab where done? SED (Quest) TriCore Other__________________
X-rays: Body part ______________Date: __________ (month/year) where was this done?
(example) Presbyterian Radiology/ Lovelace Radiology/ RAA/ XRANM/ Dr. Office: Name: ____________ MRI: Spine/ Neck/ Back/ Arm/ Leg/ Brain/ Abdomen/ Pelvis Date: _______(month/year) where was this done?
Albuquerque Imaging Center/ Presbyterian/ Lovelace/ Stand Up MRI/ Northwest Imaging/ Santa Fe Imaging/ RAA CT Scan: Spine/ Neck/ Back/ Arm/ Leg/ Brain/ Abdomen/ Pelvis Date: _______(month/year) where was this done?
Albuquerque Imaging Center/ Presbyterian/ Lovelace/ Stand Up MRI/ Northwest Imaging/ Santa Fe Imaging/ RAA Ultrasound: Pelvis/ abdomen/ blood vessels/ carotid arteries
Presbyterian/ Lovelace/ Duke City Vascular Lab/ Dr. Reddy/ Other Date: _______ (month/year) Bone Scan: Date: Lovelace/ Presbyterian/ RAA/ XRANM
Osteoporosis Screen: Date: (month/year)
Lovelace Radiology/ Presbyterian Radiology/ RAA/ High Resolution EMG/Nerve Conduction Studies: (study where your arm or leg was shocked and several muscles were
Date: Facility/ Doctor Presbyterian Neurology/ Lovelace Neurology Southwest Medical Group/ New Mexico Neurology/ New Mexico Orthopaedics/ Dr. Barrett/ Dr. Shibuya/ Dr. Gurule/ Dr. Berger/ Dr. Owensby /Dr. Harris/ Dr. Ross Goals of Treatment:
What are your goals of treatment: return to work/ care for family/ play with children/ travel comfortably/ sleep/ increase up time/ relieve pain/ resume physical therapy/ medication management/ have no goals/ other: Psychiatric History:
Have you received psychiatric care or medications for depression or other mental illness Yes/ No Have you ever attempted suicide? Yes/ No Have you ever harmed someone else? Yes/ No Have you ever been diagnosed with: Depression/ post traumatic stress disorder/ bipolar disorder/ schizophrenia/ Are you currently on medications? Yes/ No If not, were your medications discontinued by your provider or yourself? Do you feel you are stable with current treatment? Yes/ No Review of Systems:
Do you have any of the following symptoms: Headache/ fever/ chills/ sweats/ fatigue/ dizziness/ nausea/ vomiting
diarrhea/ constipation/ blood in stool/ vomiting blood/ blood in urine/ painful urination/ weight loss/ weight gain/ trouble seeing/ blurred vision/ ringing in ears/ trouble hearing/ chest pain/ swollen ankles or feet/ fainting irregular heart beat/ cold or blue feet/ persistent rash/ hair loss/ problems swallowing/ problems speaking/ numbness tingling/ tremor/ memory loss/ anxiety/ bleeding gums/ swollen lymph nodes/ other: Past Medical History:
Have you ever been diagnosed with or suffered from any of the following? Arthritis: Osteoarthritis/ rheumatoid arthritis/ lupus/ ankylosing spondylitis/ psoriatic arthritis/ osteoporosis/ scoliosis
Cancer: Type: Breast cancer/ Bladder cancer/ Cervical cancer/ Colon cancer/ Esophageal cancer/ Leukemia/
Lymphoma/ Multiple myeloma/ Ovarian cancer/ Prostate cancer/ Pancreatic cancer/ Brain cancer/ Renal cancer Skin cancer/ Stomach cancer/ Testicular cancer/ Thyroid cancer/ Uterine cancer/ Unknown type/ other: Treatment for cancer: Are you currently being treated: Yes/ No Surgery/ Chemotherapy/ Radiation Therapy
Muscular diseases: Muscular dystrophy/ polymyositis/ fibromyalgia/ other:
Nerve diseases: Multiple sclerosis/ Seizures/ Parkinson's disease/ Post Herpetic Neuralgia/ Poly Neuropathy/
Carpal Tunnel Diseases/ Ulnar Neuropathy/ Tasal Tunnel Syndrome/ Brachial Plexopathy/ Pudendal Neuropathy/ Charcot-Marie Tooth-NSMN/ Headache/ other: Cardiovascular disease: Heart attack/ CVA (stroke)/ Peripheral Artery Disease/ Deep Venous Thrombosis/
Pulmonary disease: COPD/ Asthma/ Emphysema/ Tuberculosis/ other:
Gastrointestinal disease: Hepatitis A / B / C Cirrhosis/ gallbladder disease/ pancreatitis/ other:
Genitourinary disease: Urinary tract infection/ nephrolithasis/ prostatitis/ other:
Immunologic/endocrine disorders: HIV/ AIDS/ diabetes mellitus/ gout/ hypocholesterolemia/ hypothyroidism/
hyperthyroidism/ Hashimoto's thyroiditis/ other: Skin disorders: Eczema/ psoriasis/ other:
Trauma/ Fracture: Thoracic spine/ cervical spine/ lumbar spine/ arm/ leg/ pelvis/ ribs/ concussion/ other:
Past Surgical History:
Circle any surgeries you have had in the past: Bladder Suspension/ Bunionectomy/ Carpal Tunnel/
Cataract/ Cholecystectomy/ Colon Resection/ C-Section/ Exploratory Laproscopic Surgery Hysterectomy/ LASIK/ Lumpectomy/ Mastectomy/ Nephrectomy/ Oophorectomy/ Stomach Banding/ Tonsillectomy/ Transplant/ Tubal Ligation/ Unremarkable/ other: Circle any orthopaedic surgeries you have had in the past: Arthroscopic/ Discectomy/ Elbow/ Fracture/ Hip
Family History:
Have any of your family members (blood relatives) ever had any of the following: Alcoholism/ Bi-Polar disorder/ Cancer/ CVA-Stroke/ Deep venous thrombosis/ Depression/ Diabetes Mellitus/ Drug addiction/ Emphysema/ Fibromyalgia/ Gout/ Headaches/ Heart attack/ Hypercholesterolemia/ Hypertension/ Hypothyroidism/ Lupus/ Muscular dystrophy/ Negative/ Neuropathy/ Osteoarthritis/ Rhemoatid Arthritis/ Social History:
Marital Status: Married/ single/ divorced.
Number of children:____ Age of each child?
How many of these children are currently living at home? Living Situation: I live alone. I live with spouse/ sister/ brother/ father/ mother/ other:
Occupation: Unemployed/ Unemployed due to pain/ Employed full-time/ Employed part-time/ Homemaker/
Retired/ Self-Employed/ Disabled/ On Social Security/ other: Smoking History:
Never smoked/ I smoke ___cigarettes per day/ I do not smoke anymore/ other: Alcohol Use: I do not drink/ Social drinker/ I consume _____drinks ____ days per week. Abstains at times
Recreational Drug Use: No drugs/ Nicotine/ Methamphetamine/ Cocaine-Crack/ Hallucinogens/ Heroin
Marijuana/ Amphetamines/ Opioids/ Benzodiazepines/ other: Abuse History:
Alcohol: Yes/ No How long______________? Currently using: Yes/ No Recreational Drugs: Yes/ No How long_______________? Currently using: Yes/ No Prescription Drugs? Yes/ No How long ______________? Currently using: Yes/ No If using either Recreational or Prescription drugs, please list: Physical Abuse: Yes/ No Were you: Adult/ Child Received therapy: Yes/ No Currently in therapy: Yes/ No Sexual Abuse: Yes/ No Were you: Adult/ Child Received therapy: Yes/ No Currently in therapy: Yes/ No Current Medications:
List all medications you are taking and bring all medication bottles with you at the time of your visit.
Medications Currently Taking:
Medication: Strength: Dosage:
Ex: Tylenol 500 mg 1 tablet twice daily Drug Allergy: Yes/ No If yes, explain below: Medication: Reaction:
Ex: Penicillin (Example: shortness of breath/rash/nausea/headache/dizziness).

Source: http://www.quadrahealth.com/Resources/New_Patient_Questionnaire%202013..pdf