Center for pain management

HEALTH HISTORY INTAKE QUESTIONS
Center for Pain Management, Meridian MRI, Center for Special Surgery
A representative of our practice wil call 2 to 3 days prior to your first appointment to complete the fol owing HEALTH HISTORY. Please
review these questions in advance to shorten the length of time needed for the phone call.

ALLERGIES:
Please list al al ergies and reactions you have:
FAMILY HISTORY:
Please circle any of the fol owing that are present in your family members

PAST MEDICAL:
Please circle any of the fol owing for which you have ever received treatment Any medications containing NSAIDS (aspirin or ibuprofen) I have had (or a family member has had) a problem (e.g. prolonged paralysis, awareness, malignant hyperthermia) under anesthesia: CPM New Patient Health History / Page 1 of 4 PAST MEDICAL: (continued) Hospitalizations: (please list al major il nesses with diagnosis and year)
Surgeries: (please list al surgeries and type along with year performed) (include spinal injections) When and where have you had any of the fol owing: (list results, if known) SOCIAL HISTORY:
I currently live in a:
Annual Household Income:
(please circle)
Education:
Job History:
Language:
Marital Status:

JOB HISTORY:
If you are currently NOT WORKING what was the exact date you last worked: If you are disabled, what year were you declared disabled? CPM New Patient Health History / Page 2 of 4 Yes / No Do any immediate relatives smoke? Yes / No How many times in a year do you have more than four drinks in one day? Have you ever been treated for alcohol dependency? Do any of your immediate relatives have or had an alcohol problem? Do you currently use: marijuana, cocaine, crack, ecstasy, methamphetamines, any other _______________________ drugs off the street? Have you in the past used any of the above? Do any of your first degree relatives have a substance abuse problem? Yes / No Have you ever been treated for substance abuse? How many caffeinated beverages do you drink per day? ________________
MEDICATION HISTORY:
Please list al current pain medication with mg doses and frequency (times taken per day): Please list al other medication taken including over the counter, weight loss and nutraceuticals: CPM New Patient Health History / Page 3 of 4 REVIEW OF SYSTEMS:
Please indicate if you have any of the fol owing conditions or symptoms. Circle al that apply. General Health:
Breast:
Neurological:
Cardiovascular:
Skin:
Psychiatric:
Gastrointestinal:
HEENT:
Endocrine:
Musculoskeletal:
Neck:
Hematology:
Other Medical Problems: _____________________________________________________________


Information Provided by: __________________________________ Date: ____________________
CPM New Patient Health History / Page 4 of 4

Source: http://www.indypain.com/wp-content/uploads/2013/02/NEW-PATIENT-HEALTH-HISTORY.pdf