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    Questions About Your Current Problem

    Uploaded by

    Apexa Kerai
    This patient questionnaire asks for identifying and contact information, details about the patient's current pain issue including when it began and possible causes, their pain levels over the past week rated on a scale of 0-10, what makes their pain better or worse, and their thoughts on the cause of their pain. The patient is asked to complete this before their appointment and contact the clinic as soon as possible if they need to cancel or reschedule.

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    © All Rights Reserved
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    Questions About Your Current Problem

    Uploaded by

    Apexa Kerai
    18 views2 pages
    This patient questionnaire asks for identifying and contact information, details about the patient's current pain issue including when it began and possible causes, their pain levels over the past week rated on a scale of 0-10, what makes their pain better or worse, and their thoughts on the cause of their pain. The patient is asked to complete this before their appointment and contact the clinic as soon as possible if they need to cancel or reschedule.

    Original Title

    Questionnaire Template 18

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    This patient questionnaire asks for identifying and contact information, details about the patient's current pain issue including when it began and possible causes, their pain levels over the past week rated on a scale of 0-10, what makes their pain better or worse, and their thoughts on the cause of their pain. The patient is asked to complete this before their appointment and contact the clinic as soon as possible if they need to cancel or reschedule.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    18 views2 pages

    Questions About Your Current Problem

    Uploaded by

    Apexa Kerai
    This patient questionnaire asks for identifying and contact information, details about the patient's current pain issue including when it began and possible causes, their pain levels over the past week rated on a scale of 0-10, what makes their pain better or worse, and their thoughts on the cause of their pain. The patient is asked to complete this before their appointment and contact the clinic as soon as possible if they need to cancel or reschedule.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Patient Name:

    DOB:

    MRN:

    Clinic Location:

    Patient Questionnaire

    Dear Patient:

    Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
    as possible if you cannot make your appointment. Thank you.

    Your Name

    Day Phone # Evening Phone #

    Address

    City State Zip

    Date of Birth Age

    Primary Physicians’s Name, Address, and Phone

    Referring Physician’s Name, Address, and Phone

    Preferred Pharmacy Phone #

    QUESTIONS ABOUT YOUR CURRENT PROBLEM:

    1. When did your pain problem first occur?

    2. How did it happen? Accident at work Accident at home Following


    surgery

    Please check (!) one: Car accident Other accident

    3. Have you ever had this pain before? If yes, explain.

    4. Place an X on each line between 0 and 10 to indicate your level of pain last week:

    ___________Worst this week

    ___________(no pain) 0 10 (worst possible pain)


    ___________Best this week

    __________(no pain) 0 10 (worst possible pain)

    __________Average this week

    __________(no pain) 0 10 (worst possible pain)

    5. What makes your pain worse?

    6. What makes your pain better?

    7. Yes No Do you think your pain is caused by something that is different or more serious than what your
    doctor has told you?

    8. What do you think is the cause of your pain?

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