Name* First Middle Last Date of Birth:* Month Day Year What treatment are you seeking today?* Pain Medication (Opiate Treatment) Narcotic Addiction (Buprenorphine/Suboxone) Anxiety Medication ADD/ADHD Medication Pain Management QuestionnaireHow long have you had your current pain?* Days Weeks Months Years Out 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?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your NECK pain:Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your MIDDLE BACK pain:Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your LOW BACK pain:Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your SHOULDER pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your ELBOW pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your HAND pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your ARM pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your WRIST pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your HIP pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your LEG pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your KNEE pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your ANKLE pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your FOOT pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How 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?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Narcotic addiction treatmentDo you have a history of narcotic abuse/opioid use?* Yes No How long have you been on treatment for this condition?* Never Days Months Years Are you currently experiencing any symptoms of withdrawal?* No Anxiety Depression Vomiting Muscle cramps Runny nose Shaking Are you currently receiving counseling* Yes No Anxiety QuestionnaireHow long have you experienced these symptoms?* Days Weeks Months Years Currently taking medications?* Yes No How often do you experience these symptoms?* Constant Frequent Infrequent Check 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?* Yes No Do you have difficulty concentrating?* Yes No Are you easily distracted?* Yes No Do these symptoms affect your daily routine?* Yes No Are you currently taking medication for ADD/ADHD?* Yes No