Pain Questionnaire Name* First Middle Last Date of Birth:* MM DD YYYY What treatment are you seeking today?*Pain Medication (Opiate Treatment)Narcotic Addiction (Buprenorphine/Suboxone)Anxiety MedicationADD/ADHD MedicationPain Management QuestionnaireHow long have you had your current pain?*DaysWeeksMonthsYearsOut of 10, what is your pain level today?*1 - not bad at all23456 - severe78 - very severe910 - worst pain possiblePlease choose the areas that hurt:*please, only choose top 2 areas that hurt. Head Neck Middle Back Lower Back Shoulder Elbow Hand Arm Wrist Hip Leg Knee Ankle Foot Information about your HEAD pain:Have you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your NECK pain:Have you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your MIDDLE BACK pain:Have you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your LOW BACK pain:Have you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your SHOULDER pain:Which side is your pain?*LeftRightBothHave you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your ELBOW pain:Which side is your pain?*LeftRightBothHave you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your HAND pain:Which side is your pain?*LeftRightBothHave you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your ARM pain:Which side is your pain?*LeftRightBothHave you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your WRIST pain:Which side is your pain?*LeftRightBothHave you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your HIP pain:Which side is your pain?*LeftRightBothHave you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your LEG pain:Which side is your pain?*LeftRightBothHave you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your KNEE pain:Which side is your pain?*LeftRightBothHave you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your ANKLE pain:Which side is your pain?*LeftRightBothHave you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoInformation about your FOOT pain:Which side is your pain?*LeftRightBothHave you ever had surgery on this area?*YesNoIs this pain the result of a major trauma or accident?*YesNoDoes your pain prevent you from doing daily activities?*YesNoHow would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?*YesNoIs there swelling in the area?*YesNoIs the pain worse with movement?*YesNoAre you currently taking medications for this?*YesNoNarcotic addiction treatmentDo you have a history of narcotic abuse/opioid use?*YesNoHow long have you been on treatment for this condition?*NeverDaysMonthsYearsAre you currently experiencing any symptoms of withdrawal?* No Anxiety Depression Vomiting Muscle cramps Runny nose Shaking Are you currently receiving counseling*YesNoAnxiety QuestionnaireHow long have you experienced these symptoms?*DaysWeeksMonthsYearsCurrently taking medications?*YesNoHow often do you experience these symptoms?*ConstantFrequentInfrequentCheck all of the symptoms you feel when you are anxious:* Fatigue Agitation Feeling overwhelmed restlessness Sweating Excessive worry Insomnia Nausea Palpitations Poor concentration Chest Pain Please choose any associated conditions you have:* Borderline personality Disorder Substance abuse Psychomotor retardation Alcoholism Obsessive-compulsive disorder Post-traumatic stress disorder COPD Asthma Diabetes Hyperthyroidism Drug misuse or withdrawal Withdrawal from alcohol Chronic pain Bipolar What makes your anxiety worse?* medications non-compliance with treatment hormonal imbalances psychomotor retardation stress low self-esteem abuse of alcohol or recreational drugs serious/chronic illness chronic pain traumatic events What relieves your anxiety? Rest psychotherapy cognitive behavioral therapy relaxation techniques ADD/ADHD QuestionnaireWhat behavioral problems are you experiencing?* Cannot concentrate impulsive aggression foul language Do you have associated hyperactivity?*YesNoDo you have difficulty concentrating?*YesNoAre you easily distracted?*YesNoDo these symptoms affect your daily routine?*YesNoAre you currently taking medication for ADD/ADHD?*YesNo