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PATIENT INFORMATION
First Name


Last Name


Date of Birth
Are you taking any medication for your pain? ask our office if you are uncertain
YES, I am taking pain medication
Are you taking Opioids? ie. Norco, Tramadol, Percocet, Oxy’s, MS Contin, etc.
YES, I am taking Opioids
What is your CURRENT level of pain? Do not exaggerate, so we can best assess your pain
1 2 3 4 5 6 7 8 9 10
What is your HIGHEST level of pain? Do not exaggerate, so we can best assess your pain
1 2 3 4 5 6 7 8 9 10
What does your pain FEEL like? Check all that apply
Stabbing Burning Shooting

Throbbing Aching Numb

Tingling Other
With Pain Medication, how much is your pain reduced?
Not Much At Least 30% More than 50%
Are you WORKING?
Yes No
How many hours a week are you working?
Less than 10 Hours 11 - 20 Hours

21 - 30 Hours Full Time
How long do you perform the following activities?

WITHOUT Medications
WITH Medications
⬩ Sleeping (hours)
Do you EXERCISE?
Yes No
How many times do you exercise per WEEK?
1 - 2 3 - 4 5 - 6 7 or more
How long do you exercise per SESSION?
up to 10 mins 15 - 20 mins

30 - 45 mins 45 mins or more
What exercises do you do? Check all that apply
Walking Hiking Stretching Gym

Biking Treadmill Elliptical Yoga

Swimming Weights
Are you LIMITED from performing any activities?

WITHOUT Medications
WITH Medications
⬩ Bathing / getting dressed
⬩ Light Housework
⬩ Climbing stairs
⬩ Walking
⬩ Enjoyment of life
⬩ Positive mood
With your CURRENT medications and treatments ...

In the last 30 days, how much has your pain interfered
with DAILY or GENERAL activities?
0 = "no interference", 10 = "completely interferes"
0 1 2 3 4 5 6 7 8 9 10
In the last 30 days, how much has your pain interfered
with RECREATIONAL, SOCIAL, or FAMILY activities?
0 = "no interference", 10 = "completely interferes"
0 1 2 3 4 5 6 7 8 9 10
In the last 30 days, how much has your pain interfered
with your ability to WORK and HOUSEWORK?
0 = "no interference", 10 = "completely interferes"
0 1 2 3 4 5 6 7 8 9 10
With your CURRENT medications and treatments ...

In the last 3 months, how many days have you been UNABLE to work?
0 - 3 Days 4 - 7 Days

8 - 14 Days More than 14 Days
In the last 3 months, how many days have you been
UNABLE to do housework or schoolwork?
0 - 3 Days 4 - 7 Days

8 - 14 Days More than 14 Days
Please complete this section if you are taking OPIOIDS ie. Norco, Tramadol, Percocet, Oxy’s, MS Contin, etc.

⬩ Do you use more of your medication than the prescribed dosage?
Yes No
⬩ Do you ever use your medication more often than the prescribed frequency?
Yes No
⬩ Do you ever need early refills for your pain medication?
Yes No
⬩ Do you ever feel high or buzzed after taking your pain medication?
Yes No
⬩ Do you ever take your pain medication because you are upset or to relieve / cope with problems other than your physical pain?
Yes No
⬩ Have you ever gone to more than one physician (including Emergency Room doctors) for more of your pain medications?
Yes No