Western Reserve Hospital Pain Management

Western Reserve Hospital Pain Management

New Patient Questionnaire

Insurance Company Name*

Insurance Member ID*

Primary Care Physician/Family Physician Name*

Area of Pain*

Specific location of pain

When did your pain start?*

Is your pain related to an accident?*

Select or enter value

Is the pain related to a work injury?*

Select or enter value

Where is your pain located?*

Please be specific.

What makes your pain better?*

What makes your pain worse?*

Past Medical History

Please list all past surgeries:*

Please list any other medical conditions:*

Previous Evaluation and Treatment for your Current Problem

Have you seen any other pain management clinics?*

Yes

Have you had any of these tests completed for this condition?

Regular X-Rays*

Yes

EMG/ Nerve Conduction*

Yes

Have you had any of the following treatements for this condition? If YES, please indicate the effectiveness of the treatmenet received.

Medications

List all of your current medications, dosage and how many times per day you take them. Include ALL prescribed, over-the-counter, vitamins and herbal medications, supplements.

Medication 1