Patient Name: _______________________________________ |
Social Security #: ____________________________________ |
Date of Birth: ________________________________________ |
| 1. | Does this patient experience or complain of pain in part of his/her body? ____Yes _____No |
| If yes, where does (s)he experience this pain? | |
| _____________________________________________________________________ | |
| 2. | Are the complaints of pain within the range that is reasonably related to a physical ellness that has been diagnosed? ____Yes _____No |
| If yes, where does (s)he experience this pain? | |
| _____________________________________________________________________ | |
| 3. | On the basis of clinical observations and diagnostic impressions, does this patient experience: |
| A. Chronic Pain? _____ Yes _____ No If so, where? | |
| _____________________________________________________________________ | |
| B. Acute Pain? _____ Yes _____ No If so, where and upon what activity? | |
| _____________________________________________________________________ | |
| 4. | Is the pain: |
| Relieved by medication? _____ Yes _____ No | |
| Where? ______________________________________________________________ | |
| Relieved by heat? _____ Yes _____ No | |
| Where? ______________________________________________________________ | |
| Other, please explain: ____________________________________________________ | |
| Relieved by none of the above: _____________________________________________ | |
| 5. | If the pain is relieved by one of the above, does that therapy or medication alleviate the pain completely? _____Yes _____No |
| 6. | Do you believe this patient experiences so much pain that (s)he is unable to work on a sustained basis? _____Yes _____No |
| 7. | Is the level of pain suffered by the patient likely to increase if the patient returns to work? _____Yes _____No |
| _____________________________________________________________________ | |
| _____________________________________________________________________ |
| Date Report Completed: | ______________________________ |
| Signature of Physician: | ______________________________ |
| Physician Name: | ______________________________ |
| Address: | ______________________________ |
| Telephone: | ______________________________ |
| Specialty: | ______________________________ |