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bergComprehensive Pain Management CenterIn order to make the most of your visit, we require this form be completed to thebest of your ability and sent to the Comprehensive Pain Management Center.After completing, please mail, email or fax to the information listed below. Pleasenote: appointments are prioritized and made according to the date that thisquestionnaire is returned to us, not by the date we receive the referral. Pleasereturn this form to the Comprehensive Pain Management Center as soon aspossible so we can begin processing your referral.ANMC Neurosurgery/Comprehensive Pain Management Center4315 Diplomacy Dr.Anchorage AK 99508Phone: 907-729-2525Fax: 907-729-2526If an appointment is made, please be sure to bring a sufficientamount of your medications. Prescriptions or medicationswill not be given on the visit.Page 1 of 15Patient NameDate of BirthANMC Comprehensive Pain CenterRevised November 2013

Page 2 of 15ANMC Comprehensive Pain CenterRevised November 2013

Comprehensive Pain Management Questionnaire1. What is the main reason for your referral to the Comprehensive Pain Center?2. What do you expect from our pain program? (select the one best answer)o A diagnosis (to help find the cause of pain)o Help in coping with the paino A reduction in paino A cureo No expectationso Don not know what to expect3. What types of treatment do you expect from your visit to the Comprehensive Pain Center?o Consultation only (advice only to you and your primary care physician)o Counselingo Stress Managemento Physical Therapyo Drug treatmento Acupunctureo Surgeryo Relaxation therapyo Biofeedbacko Injections or nerve blockso Electrical stimulation such as TENS unito Spinal cord stimulatoro Implant medication pumpo Don’t knowo Other (describe)4. When did your pain problems begin?/ /Day/Month/Year5. Under what circumstances did your pain begin?o Accident at worko Accident at homeo Following Surgeryo Pain just began with no known causeo At work, but not an accidento Motor Vehicle Accidento Following illnesso Other (describe)Page 3 of 15ANMC Comprehensive Pain CenterRevised November 2013

6. Is your ngingBurningThrobbingShooting7. In general, when is your pain the worst?o Morningo Afternoono Eveningo No typical pattern8. What makes your pain worse? (circle all that apply)Bending backwardBending forwardClimbing ght touchSexual activitySittingStandingStressful situationsWalkingWorkOther: (describe)9. What relieves the pain? (circle all that apply)Bath/showerExerciseHeatColdLying DownMedicationsMeditationPhysical TherapyRelaxationSittingStandingWalkingOther: (describe)Page 4 of 15ANMC Comprehensive Pain CenterRevised November 2013

10. Where is your pain? Please be as specific as possible.11. Please rank your main painful areas in order form 1 to 10 with 1 being the most painful.Head, face, mouthCervical (neck) regionUpper shoulder and upper limbsThoracic (mid to upper back) regionAbdominal RegionLower back, lumbar spine, sacrumPelvic regionAnal, perineal, genitalGeneralized painPage 5 of 15ANMC Comprehensive Pain CenterRevised November 2013

12. Please rate your pain by filling in the circle that describes how much pain you have right now:No pain12345678910 Worst possible pain13. Please rate your pain by filling in the circle that describes your pain at its least in the last 24hours:No pain12345678910 Worst possible pain14. Please rate your pain by filling in the circle that describes your pain at its worst in the last 24hours:No pain12345678910 Worst possible pain15. Please rate your pain by filling in the circle that describes your pain on average:No pain12345678910 Worst possible pain16. In the last 24 hours, how much pain relief have pain treatments or medications provided? Pleasefill in the circle of the one percentage that most shows how much relief you have received:None 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% best possible relief17. Fill in the circle that describes how, during the last 24 hours, pain has interfered with your:A. General Activity:Does not interfere12345678910 Completely interferes12345678910 Completely interferes12345678910 Completely interferesB. Mood:Does not interfereC. Walking Ability:Does not interfereD. Normal Work: (includes both work outside the home and housework)Does not interfere12345678910 Completely interferesE. Relations with other people:Does not interfere12345678910 Completely interferes12345678910 Completely interferes12345678910 Completely interferes12345678910 Completely interferesF. Enjoyment of life:Does not interfereG. Sexual Activity:Does not interfereH. Sleep:Does not interferePage 6 of 15ANMC Comprehensive Pain CenterRevised November 2013

18. Have you ever been treated at another pain management center or program? ᴏ No ᴏ YesIf yes, where? When?What did they do?19. In the past 12 months (year), how many times have you been to the emergency room for yourpain?20. Have you ever had the following types of treatment for your pain problem, and what was theresult?Indicate paintherapies ug DetoxificationsSurgeryEpidural Steroid InjectionsFacet Joint InjectionsTrigger Point InjectionNerve (lumbar, sympathetic, stellateganglion, etc) blocksOther injectionsSpecify:Spinal Cord StimulationMedication pumpRadiation TreatmentPhysical TherapyExerciseManipulations/MobilizationTractions Exercise/AerobicConditioningPassive (heat, ice, gentle massage,ultrasound)Aqua/water/pool therapyTrigger point therapy/deep tissuemassage/ acupressureOccupational TherapyAcupunctureChiropracticOrthotics (corrective shoe insert)Prosthetics(braces, supports. etc)TENS or other Electric StimulationBiofeedback/RelaxationYogaHypnosisGroup TherapiesPsychological Counseling for painOther:Page 7 of 15ANMC Comprehensive Pain CenterRevised November 2013

21. What medical tests have been done to evaluate your pain?TestDate (approximate)Results (if known)o X-Ray/ /o CT Scan/ /o Myelogram / /o MRI/ /o Bone Scan / /o EMG/ /o EKG/ /o Other/ /OTHER MEDICAL HISTORY22. Current Medications;Please list all medications that you are taking now or attach your own medication list.Include over the counter, herbal, vitamins, and other supplemental medications.DoseHow OftenPrescribingMedicationWhat for?Mg or # of pills # times per dayDoctorPage 8 of 15ANMC Comprehensive Pain CenterRevised November 2013

23. List all other pain medications that you have tried in the past.Maximum Length ofIf stopped,Name of MedicationTriedDoseTherapywhy?Pain deine, Tylenol #3, #4, 222Fentanyl Lollipops (Actiq)Fentanyl Patches (Duragesic)Fentanyl Tablet (Fentora)Hydrocodone (Vicodin, Lortab,Norco)Hydromorphone (Dilaudid)Methadone (Dolophine)Morphine (Avinza, Kadian, MSContin, MSIR)Meperidine (Demerol)Oxycodone (Percocet, Oxycontin)Oxymorphone (Opana)Propoxyphene (Darvon)Tapentadol (Nucynta)Tramadol (Ultram, Ultram ER,Ulracet, Ryzotl)OtherAnti-Seizure MedicinesCarbamazepine (Tegretol)Gabapentin (Neurontin)Lacosamide (Vimpat)Lamotrigine (Lamictal)Oxycarbazepine (Trileptal)Tiagabine (Gabatril)Topiramate (Topamax)Zonisamide (Zonegram)Pregabalin (Lyrica)Valproic Acid (Depakole)OtherMuscle RelaxantsBaclofen (Lioresal)Carisoprodol (Soma)Clonazepam (Klonopin)Cyclobenzaprine (Flexeril)Diazepam (Valium)Metaxolone (Skelaxin)Methocarbamol (Robaxin)Tizanidine (Zanaflex)OtherSide EffectsNo sideeffectsPage 9 of 15ANMC Comprehensive Pain CenterRevised November 2013

Name of MedicationTriedMaximum Length ofDoseTherapyAnti-DepressantsIf stopped,Why?Side EffectsNo sideEffectsAmitriptyline (Evavil)Bupropion (Wellbutrin)Citalopram (Celexa)Desipramine (Norpramin)Desvenlafaxine (Pristiq)Duloxetine (Cymbalta)Escitalopram (Lexapro)Fluoxetine (Prozac)Fluvoxamine (Luvox)Hyp. Perforatum (St John’s Wort)Milnacipran (Savella)Mirtazepine (Remeron)Nefazodone (Serzone)Nortriptyline (Pamelor)Paroxetine (Paxil)Sertraline (Zoloft)Trazadone (Deseryl)Venlafaxine (Effexor)OtherAnti-Anxiety/ Other Mood StabilizersAlprazolam (Xanax)Chlordiazepoxide (Librium)Clonazepam (Klonopin)Lithium (Eskalith)Olazepine (Zyprexa)Phenelzine (Nardil)Quetiapine (Seroquel)Resperidone (Risperdal)OtherSleepMelatoninEszopiclone (Lunesta)Ramelton (Rozerem)Temazepam (Restoril)Triazolam (Halcion)Tylenol-PMZolpidem (Ambien)OtherPage 10 of 15ANMC Comprehensive Pain CenterRevised November 2013

Name of MedicationTriedMaximum Length ofDoseTherapyAnti-InflammatoriesIf stopped,Why?Side EffectsNo sideEffectsCelecoxib (Celebrex)Ibuprofen (Advil, Motrin)Meloxicam (Mobic)Naproxen (Aleve, Naprosyn)Nabumetone (Relafen)Rofecoxib (Vioxx)Valdecoxib (Bextra)OtherOtherAcetaminophen (Tylenol)KetaminePramipexole (Mirapex)Pyridostigmine (Mestinon)Lidocaine Patch (Lidoderm)OtherPage 11 of 15ANMC Comprehensive Pain CenterRevised November 2013

24. .Review of Systems: PLEASE CHECK ALL THAT APPLYConstitutional:Eyes:Gastrointestinal:o Feverᴏ Blurredᴏ Heartburno Chillsᴏ Double Visionᴏ Nauseao Weight Lossᴏ Photophobiaᴏ Vomitingo Malaise/Fatigueᴏ Eye Painᴏ Abdominal Paino Diaphoresis (Sweaty) ᴏ Eye Dischargeᴏ Diarrheao Weaknessᴏ Eye Rednessᴏ Constipationo None of the Aboveᴏ None of the Above ᴏ Blood in Stoolᴏ Melenaᴏ None of the AboveSkin:Cardiovascular:Genitourinary:o Rashᴏ Chest Painᴏ Painful Urinationo Itchingᴏ Palpitationsᴏ Urgencyo Nail Changᴏ Gasping for Breath ᴏ Frequencyo Skin Disorderᴏ Claudicationᴏ Blood in Urineo None of the Aboveᴏ Leg Swellingᴏ Flank Painᴏ High Blood Pressure ᴏ Urinaryᴏ Difficulty breathing ᴏ Incontinenceat nightᴏ None of the AboveEndo/Heme/Allergy:ᴏ Easy Bruise/Bleedᴏ Environment Allergiesᴏ Frequent Urinationᴏ Diabetesᴏ Thyroid Disorderᴏ Clotting Disorderᴏ None of the AboveNeurological:ᴏ Dizzinessᴏ Tinglingᴏ Tremorᴏ Sensory Changeᴏ Speech Changeᴏ Focal Weaknessᴏ Seizuresᴏ Loss of Consciousnessᴏ None of the AbovePsychiatric:ᴏ Depressionᴏ Suicidal Ideasᴏ Substance Abuseᴏ Hallucinationsᴏ Nerve/Anxiousᴏ Insomniaᴏ Memory Lossᴏ None of the AboveHent:Respiratory:Musculoskeletal:o Headachesᴏ Coughᴏ Muscle Paino Hearing Lossᴏ Bloody Coughᴏ Neck Paino Ringing in Earsᴏ Sputum Production ᴏ Back Paino Ear Painᴏ Shortness of Breath ᴏ Joint Paino Ear Dischargeᴏ Wheezingᴏ Fallso Nose Bleedsᴏ Asthmaᴏ Fractureso Congestionᴏ Sleep Apneaᴏ Herniated Disco Difficulty Breathingᴏ None of the Above ᴏ None of the Aboveo Sore Throato None of the Above25. How much sleep do you average each night? hours.26. Is your sleep disturbed at night? ᴏ No ᴏ Yes27. Do you have any medical devices implanted in your body?Infusion Pumpᴏ No ᴏ YesSpinal Cord Simulator ᴏ No ᴏ YesRidsᴏ No ᴏ YesProsthesisᴏ No ᴏ YesPacemakerᴏ No ᴏ YesPortacathᴏ No ᴏ YesOtherPage 12 of 15ANMC Comprehensive Pain CenterRevised November 2013

28. List all hospitalizations and/or surgeries:Neurological/OrthopedicCraniotomy/Brain SurgeryCervical FusionCervical LaminectomyLumbar FusionLumbar LaminectomySurgical Treatment of FractureHip ReplacementKnee ArthroscopyKnee ReplacementAbdominalHernia RepairAbdominal Wall Defect RepairGastric BypassColectomyColostomyLysis of ean SectionTURP/Transurethral Resection of ProstateProstatectomyVascular/LungFemoral BypassAbdominal Aortic Aneurysm RepairHeart Valve SurgeryCoronary Artery Bypass GraftThoracotomy/Lung SurgeryDates (approximate)Dates s (approximate)29. Please list any medical conditions in your immediate family such as diabetes, arthritis, substanceabuse, psychiatric, etc.Page 13 of 15ANMC Comprehensive Pain CenterRevised November 2013

PSYCHOLOGICAL AND SUBSTANCE USE30. Have there been any other stressful life experiences recently? ᴏ No ᴏ YesIf yes, explain:31. Have you ever had thoughts of suicide or harming yourself? ᴏ No ᴏ YesHarming someone else? ᴏ No ᴏ Yes32. Please mark the appropriate answer to the following questions:During the past month, have you been tense or anxious?ᴏ Never ᴏ Seldom ᴏSometimes ᴏFrequently ᴏ AlwaysDuring the past month, have you been depressed or discouraged?ᴏ Never ᴏ Seldom ᴏSometimes ᴏFrequently ᴏ Always33. Have you been under the care of a mental health professional? ᴏ No ᴏ YesIf yes, how often34. Would you like to have access to a mental health professional? ᴏ No ᴏ Yes35. Are you, or have you ever been, involved with any of the following:CurrentlyUsed inItemNeverUsethe PastMarijuanaCocaineMethamphetamineHeroinOther illicit/street drugComments36. Do you smoke? ᴏ No ᴏ YesIf yes, How many packs a day? How long have you smoked?If no, have you ever smoked? ᴏ No ᴏ YesIf yes, when did you smoke? How many packs per day did you smoke?37. Please answer all that apply:Have you felt you ought to cut down on your drinking or drug use?ᴏ No ᴏ Yes ᴏ Does not applyHave people annoyed you by criticizing your drinking or drug use?ᴏ No ᴏ Yes ᴏ Does not applyHave you felt bad or guilty about your drinking or drug use?ᴏ No ᴏ Yes ᴏ Does not applyHave you ever had a drink or used drugs first thing in the morning to steady your nerves or to get ridof a hangover?ᴏ No ᴏ Yes ᴏ Does not applyDo you drink alcohol to decrease or relieve the pain?ᴏ No ᴏ Yes ᴏ Does not applyPage 14 of 15ANMC Comprehensive Pain CenterRevised November 2013

38. Education Level:ᴏ 8th grade or less ᴏ Some High Schoolᴏ High School Graduate or GEDᴏ Some Collegeᴏ Associate’s Degree ᴏ Bachelor’s Degreeᴏ Technical or Trade School Graduateᴏ Completed Graduate or Professional School Degree (e.g. Master’s, Ph.D. M.D., Etc)39. Currently Employed? ᴏ No ᴏ Yes (select the best description for you)ᴏ Homeworkᴏ Not working due to painᴏ Not working due to other reasonsᴏ On leave from workᴏ Retired due to painᴏ Retired not due to painᴏ Working full timeᴏ Working part time39. Describe your current (or most recent) occupation and duties:When did you last work?40. In the past six months, how many full days of work have you missed because of pain?ᴏ 5 days ᴏ 6-14 days ᴏ 3-4 weeks ᴏ 1 moths41. What exercise of recreational activities do you enjoy?42. Please mark the statements that apply to you:Disability:ᴏ Not receiving or seeking disabilityᴏ Not receiving but seeking or planning to seek disabilityᴏ Receiving disabilityLitigation/Lawsuit: (s)ᴏ No (and not intending) pain-related litigation/lawsuit or legal involvementsᴏ Currently in pain-related litigation/lawsuit or pain-related legal involvementᴏ Past litigation/lawsuit or legal involvement related to pain conditionMotor Vehicle Accidents:ᴏ Pain not related to motor vehicle accidentᴏ Pain related to motor vehicle accident and settlement pendingᴏ Pain related to motor vehicle accident but no settlement pending or necessaryDo you have any other litigation or lawsuits ongoing, pending, or under consideration? ᴏ No ᴏ YesIf yes, explain:Page 15 of 15ANMC Comprehensive Pain CenterRevised November 2013

return this form to the Comprehensive Pain Management Center as soon as possible so we can begin processing your referral. ANMC Neurosurgery/ Comprehensive Pain Management Center 4315 Diplomacy Dr. Anchorage AK 99508 Phone: 907-729-2525 Fax: 907-729-2526 If an appointment is made, please be sure to bring a sufficient amount of your medications.