Laden...

Patient Qs
This information will let us know more about you.

PERSONAL INFORMATION


  • Male


    Sex

    Female

HISTORY OF PRESENT ILLNESS







History of Present Illness ( Cont.)

Oswestry DI

This section is designed as an assessment tool to give the doctor information on how your pain affected your everyday life. Please answer every section and mark in each section only the one box that best applies to you. You may consider that two statements in any one section relate to you, but please mark the box which closely describe your problem











PAIN RELATED TREATMENT HISTORY

A- Medications





  • Any Other Pain Related Medications:




PAIN RELATED TREATMENT HISTORY


B- Procedures


C- Surgery


D- Others
Others (Check all that applies) if you tried any of the following to relieve the Pain?






















E- Clinic & Doctor



ALL PAIN RELATED DIAGNOSTIC TESTS

  • Xray
    • Neck

    • Back

    • Knee

    • Hip


  • MRI
    • Neck

    • Back

    • Knee

    • Hip


  • CT Scan
    • Neck

    • Back

    • Knee

    • Hip


  • EMG? BODY PART
    • Arm

    • Leg

  • Bone Scan?

SOCIAL & LIFESTYLE HISTORY



  • Current Use

    Previous Use

    How much? How long? When Stopped

  • Regular Use

    Previous Use

    How much? How long? When Stopped

  • Regular Use

    Previous Use

    How much? How long? When Stopped

  • Current Use

    Previous Use

    How much? How long? When Stopped

  • Have you been in any Chemical Dependence Rehabilitation Program?
  • III- Living Condition

  • IV- Current Daily Physical Activity Level



  • V- Your Mood Most of the time?

  • VI- Sleep


    Rested in the morning?

  • Do you currently Work?

  • Are your symptoms related to injury or work related injury?

SOAPP® Version 1.0 - SF

The following are some questions given to all patients at the Pain Management Center who are on or being considered for opioids for their pain. Please answer each question as honestly as possible. This information is for our records and will remain confidential. Your answers alone will not determine your treatment. Thank you.

Please answer the questions below using the following scale: 0 = Never, 1 = Seldom, 2 = Sometimes, 3 = Often, 4 = Very Often









  • HOSPITALIZATION

  • FAMILY HISTORY


Disclaimer
Please be advised that completing preliminary health and insurance questionnaires does not establish a physician-patient relationship with this practice. Dr. Beshai will review your health history and conduct an initial evaluation to determine wether you are a suitable candidate and if our practice will be able to help you with your condition