IH-UMC - Pain Assessment Form For New Patients

Today's Date: * +

Who are you seeing today? *

If seeing a Specialist who is your PCP? *

Patient Information

First Name *

Last Name *

MI

Date of Birth * +

Social Security Numbeer

Gender

Identify As?

Please Identify where you are having the most pain: *

Select a number for each question below.

What is the average level of pain you have on a daily basis? *

What effect does treatment of pain have on your ability to perform daily activity? *

How sad, blue or depressed has your pain caused you to feel? *

How much nervousness or anxiety do you experience due to your pain? *

How much suffering do you experience because of your pain? *

What effect does treatment of pain have on your ability to perform daily activity? *

When did you start to experience this pain? *

How often do you experience pain? *

Daily

On and Off

Other

What makes your pain worse? *

What makes your pain better? *

Have you tried any of this medication for your pain? Please check medication:

IR/SR Opioids:

Mixed Opioids:

NSAIDS:

Sedatives/Relaxants:

Antidepressants:

Anticonvulsants:

Other:

Codeine	Fentanyl	Hydromorphone	Oxycodone	Meperidine	Methadone
Morphine	Other

Codeine/AP AP	Hydrocodone/APAP	Hydrocodone/Ibuprofen	Oxycodone/APAP
Oxycodone/ASA	Propoxyphene/APAP	Other

Capsaicin	Clonidme/Catapress	EMLA	Lidocaine patch	Prednisone
Tramadol	Tramadol/APAP	Other