Patient Questionaire

Pain Management and Rehabilitation Center

4793 Manhattan Drive Rockford, Illinois 61108

Phone: 815-398-7246 Fax: 815-398-7276


Patient Initial Questionnaire


Patient Name____________________________________________________________________________


General Medical History

Please comment on your general health status. Check any items which are presently a problem. Please explain any check items and list other doctors you may be seeing for those conditions.


________ Heart ___________________________________________________________________________
________Lungs ___________________________________________________________________________
________Asthma __________________________________________________________________________
________ Liver ____________________________________________________________________________
________ Hepatitis ________________________________________________________________________
________ Cirrhosis ________________________________________________________________________
________ Kidneys _________________________________________________________________________
________ Diabetes ________________________________________________________________________
________ Hypertension ___________________________________________________________________
On any Blood thinners? Yes/ No
________Medication Allergies______________________________________________________________

Please list ALL medications you are currently taking and what they are taken for.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pain History
When did your pain start (Month/ year)? ________________________________________________
What were you doing at the time? ______________________________________________________
Is your pain constant or sporadic? _____________________________________________________
What makes your pain worse or better? ________________________________________________ _______________________________________________________________________________________
Where is your pain located now? _______________________________________________________ _______________________________________________________________________________________
Is your pain: Getting worse Staying the same Improving
Circle the quality of your pain: Shooting Dull Ache Cramping Sharp Burning Stabbing Severe Ache
Further Comments ____________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
On a scale of 1-10- with 1 being no pain and 10 being the worst pain ever- my pain is a _______________________________________________________________________________________
How many back surgeries have you had? (If none, proceed to question 13) ___________
How long did you have acceptable relief after your last back surgery? _______________________________________________________________________________________
Did you return to work after surgery? If so, for how long? ____________________________ _______________________________________________________________________________________
Did your present injury occur at work? Yes No
Have you been off work with the current problem? If so, for how long? _______________________________________________________________________________________
Describe your occupation. _________________________________________________________ _______________________________________________________________________________________
If you have leg pain, how long have you had it? ______________________________________
If you have back pain, how long have you had it? ____________________________________
Does the pain inhibit your activity? Yes No
Does the pain awaken you? Yes No
How often do you take pain medication? ____________________________________________
Have you ever applied for workman's compensation? Yes No
Who is the attorney involved with your case (if any)? _________________________________ _______________________________________________________________________________________
If you have any questions, please feel free to ask us.
Signature:________________________________________