Intervention Medicine Paperwork Interventional Medicine Step 1 of 12 8% Do you or have ever had any heart problems in your past or currently? Yes No Have you ever in the past or do you currently take any blood thinners? (Asprin, Coumadin, Plavix) Yes No Are you currently taking any anti-inflammatories? (Motrin, Advil, Naproxen, Mobic, etc) Yes No Have you ever in the past or do you currently take any drugs to maintain normal heart rhythm? Yes No If you have high blood pressure, has it ever been over 180/100? Yes No Have you ever had a seizure? Yes No Do you have allergies to iodine? Yes No Have you had any IV (intravenous) dye injections? Yes No Have you had any recent infections? (past three months) Yes No Have you ever had an infection with MRSA (Methicillin-Resistant Staphylococcus Aureus)? Yes No Do you have a history of retinal detachment or glaucoma? Yes No Do you have diabetes? If so, are you insulin dependent? Yes No Females Only: Is there any chance you could be pregnant? Yes No Females Only: Are you currently breast feeding? Yes No What is/are your main problems?When did your problems starts? (weeks, months, years, specific dates) What caused your symptoms? (fall, motor vehicle accident, etc) How would you describe your pain? Choose all that apply Achy Dull Sharp Burning Throbbing Numbness Which side hurts the most? Achy Right Left Both sides The middle Have you had any muscle spasms or tightness? If so, where? Have you had any numbness and if so, where? Does the pain tend to travel anywhere? (down the leg, arm, etc) Over the past few weeks, is your pain Improving Worsening Not getting any better The same Is the pain constant or intermittent (off and on) Yes No What worsens the pain?StandingSittingLying DownWalkingTwistingDrivingReachingHeatColdCoughingSneezingLeaning ForwardOtherWhat reduces the pain?StandingSittingLying DownWalkingTwistingDrivingReachingHeatColdCoughingSneezingLeaning ForwardOther How would you rate your pain level on a typical day from 1 to 10. 0 = No pain 1,2,3 = Minor aches 4,5,6 = Moderate 7,8,9 = Intense 10 = Emergency What can you no longer do because of pain? (Goals of treatment) Has this affected your sleep? Yes or No. If so, how many hours do you sleep. Please list prior pain medicineHave you ever had any of the following studies? EMG (nerve study) MRI CT Scan X-rays Bone Scan Have you ever had any of the following procedures or therapies? Chiropractic Physical Therapy Epidural Join Injections Do you have a primary care physician? Please list name and location Do you have a pharmacy you use? If so which pharmacy and where is it located? What is your past/current medical history?DiabetesCancerLiver DiseaseDepressionsHeart diseaseUlcers/GI diseaseStrokeKidney diseaseAnxietyHigh blood pressureAsthma/EmphysemaBipolar DisorderOtherWhat is your past surgical history?DiabetesCancerLiver DiseaseDepressionsHeart diseaseUlcers/GI diseaseStrokeKidney diseaseAppendix/Gall bladder removalTonsillectomyHernia repairC-SectionHysterectomyOther Are you taking any prescription medications? If yes please list.Are you taking any over the counter medications? If yes, please list Are you allergic to any medications? Please provide drug/reaction Are you Married Single Divorced Widowed Do you have any children? Yes No Alcohol use None Social Moderate Daily (more than 2) Do you smoke Yes No How many packs a day Have you ever taken/used illicit drugs? Yes No What is your occupation? Full or Part Time Are you working full or light duty? Full Light Duty Not working Have you tried to return to work? Yes No Is there a lawyer involved? Yes No Have you applied or intend to apply for social security? Yes No Do you have any hobbies or activities that require a moderate level or physical activity? Family HistoryGenetic DiseasesStrokeDiabetesHeart DiseaseMuscle DiseaseNeurological DiseaseAlcoholism or Illegal Substance AbuseOtherOther Have you had any of the following symptoms i nthe past month?Weight LossRinging in the earsRecent vision changesCoughNausea or VomitingChange in Urinary HabitsEasy bruisingRecent memory lossDifficulty holding urine/bowel movementsFever/ChillsRecent Hearing LossChest PainWheezingDiarrhea/ConstipationBlood in UrineDiscolorationDepressionNight sweatsDizzinessShortness of BreathAbdominal PainBloody or black stoolsSkin RashNew onset SeizuresHot or Col Temp Intolerance
