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    Chronic Pain Clinic Patient History Sheet

    Uploaded by

    Belal N. Mahfouz
    This document contains a patient history sheet for a chronic pain clinic. It collects information about a patient's pain symptoms, medical history, medications, and test results. The sheet gathers details on the patient's name, age, contact information, duration and characteristics of pain, pain level ratings, associated symptoms, medication usage and effectiveness, sleep issues, aggravating and relieving factors, medical conditions, injuries, surgeries, and depression screening. Laboratory results and imaging reports are also documented. The medical plan section outlines the patient's prescribed medications, treatment response and tolerance, and plans for follow up visits.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Chronic Pain Clinic Patient History Sheet

    Uploaded by

    Belal N. Mahfouz
    123 views4 pages
    This document contains a patient history sheet for a chronic pain clinic. It collects information about a patient's pain symptoms, medical history, medications, and test results. The sheet gathers details on the patient's name, age, contact information, duration and characteristics of pain, pain level ratings, associated symptoms, medication usage and effectiveness, sleep issues, aggravating and relieving factors, medical conditions, injuries, surgeries, and depression screening. Laboratory results and imaging reports are also documented. The medical plan section outlines the patient's prescribed medications, treatment response and tolerance, and plans for follow up visits.

    Original Description:

    Pain clinic Sheet

    Original Title

    Chronic Pain Clinic

    Copyright

    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    This document contains a patient history sheet for a chronic pain clinic. It collects information about a patient's pain symptoms, medical history, medications, and test results. The sheet gathers details on the patient's name, age, contact information, duration and characteristics of pain, pain level ratings, associated symptoms, medication usage and effectiveness, sleep issues, aggravating and relieving factors, medical conditions, injuries, surgeries, and depression screening. Laboratory results and imaging reports are also documented. The medical plan section outlines the patient's prescribed medications, treatment response and tolerance, and plans for follow up visits.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    123 views4 pages

    Chronic Pain Clinic Patient History Sheet

    Uploaded by

    Belal N. Mahfouz
    This document contains a patient history sheet for a chronic pain clinic. It collects information about a patient's pain symptoms, medical history, medications, and test results. The sheet gathers details on the patient's name, age, contact information, duration and characteristics of pain, pain level ratings, associated symptoms, medication usage and effectiveness, sleep issues, aggravating and relieving factors, medical conditions, injuries, surgeries, and depression screening. Laboratory results and imaging reports are also documented. The medical plan section outlines the patient's prescribed medications, treatment response and tolerance, and plans for follow up visits.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    At a glance
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    The document outlines a patient history sheet used to collect information about a patient's chronic pain condition. It collects details about the pain itself as well as potential contributing medical, injury and surgical history.

    The patient history sheet collects information about the patient's demographic details, details of the pain such as duration and characteristics, associated symptoms, pain triggers and relievers, current medications, medical conditions and surgeries.

    The patient history sheet assesses factors like sleep quality, activities that increase pain, symptoms like numbness, and responses to touch that could provide insight into the pain. It also documents the patient's assessment of their current pain level and changes in pain levels.

    Anesthesia, ICU and Pain Management Department

    Interventional Pain Management Unit

    Chronic Pain Clinic


    Patient History Sheet
    Provisional Diagnosis :

    1- Name: Resident Name:


    .. Date :
    /
    / 20
    2- Age : Sex : .. Religion : .. Occupation: .
    3- Phone No. : .. Clinic Staff Name
    ..
    4- Referring Physician: Bw. Height .
    BMI
    5- Marital Status : Single / Married / Separated / Other : 6 Duration of Pain ( Days / Months / Years ) : .
    7- How would you assess your pain at this moment :
    None mild
    Max
    0
    9

    2 3
    10

    Moderate
    4

    Sever

    excruciating
    7

    8 Describe the course of the pain :


    Persistent pain
    without any
    fluctuation
    Persistent pain
    with sudden sever
    pain attacks

    Pain attacks
    without any pain in
    between
    Moderate pain
    attacks with mild
    pain in between

    9- Does the pain radiate / spread from one part to other parts your body?

    Anesthesia, ICU and Pain Management Department


    Interventional Pain Management Unit

    Never

    Hard
    ly
    Note
    d

    Slightly

    Moderate
    ly

    Strongl
    y

    Very
    Strongly

    Do you suffer from burning sensation


    in the marked area
    Do you suffer from pricking of needle
    in the marked area
    Do you find Touching ( like touching
    of clothes , blankets ) in this area
    painful
    Do you have sudden pain attacks in
    this area
    Do you suffer from numbness in the
    area that you marked
    Does slight pressure in this area
    ( e.g with a finger ) trigger pain
    Does Cold or Hot water increase your
    pain?

    11- Associated complains with pain ( Vomiting , Fever , Headache , Etc) .


    12- When does pain get Worse ? ( Morning / Evening / All over the day )
    13 Describe your sleep pattern :
    (Wake up refreshed/ Wake up fatigued/Toss and turn frequently/Can't find a comfortable position )

    14- What things increase your pain ?


    ( Lying / bending forward / sitting / changing of posture like sitting to standing / walking / lifting
    something etc )

    15-Medication used to reduce pain ? ..


    16- How much relief are you getting from these medicines ? ( Not at all / Partial relief /
    complete relief )
    17 Do you suffer from any medical diseases ?
    ( DM / Hypertension / ISHD / Hypothyrodism / Hyperthyrodism /Renal or Impairment,
    etc )
    18 Do You have any injuries ? if yes , Please describe it. Start with date of injury

    19 Do You Have any operations ? if yes , Please describe it. Start with date of injury

    Not at
    all

    Several
    Days but
    less than

    Several
    Days but
    more than

    Nearly
    every day

    Anesthesia, ICU and Pain Management Department


    Interventional Pain Management Unit
    half a month

    half a
    month

    Little interest or pleasure in doing things


    Feeling down, depressed or hopeless
    Finding trouble in falling or staying asleep or
    sleeping too much
    Feeling tired or have little energy
    Poor appetite or over eating
    Trouble in concentrating on things , such as reading
    the newspaper or watching TV
    Moving or speaking so slowly or restlessly that other
    people could have noticed
    Thoughts that you would be better off dead or
    thoughts of killing yourself

    Imaging Report

    ..

    Labs
    Date

    TLC

    Hb

    Plts

    INR

    ESR

    Bun/Crea
    t

    AST/
    AlT

    Other

    Medical Plan and Follow Up


    Date
    of
    visit

    Medications

    Tolerance

    Response

    Other
    Measures

    Anesthesia, ICU and Pain Management Department


    Interventional Pain Management Unit

    Other Measurements and plans

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