If you are experiencing a level 10 pain, you should seek medical attention immediately!

APPT DATE:

APPT TIME:

ARRIVAL TIME:

Patient's Name:

ACCT#:

DOB:

Insurance:
0-2 3-4 5-6 7-8 9 10
 Short Term  
ex: stub a toe 		Achy
ex: always there ex: 		Sharp
constant pain		 Pain that stops function
ex: can't dress themselves		  Intense
ex: sweating		  Torturing
ex: in ER Hospital
1. Throughout our lives, most of us have had pain from time to time
(such as minor headaches, sprains, and toothaches).
Have you had pain other than these everyday kinds of pain today?
  Yes No
2. Where do you feel your pain?
 
3. Please rate your pain by selecting the one number that best describes your pain at its LEAST in the last
24 hours.
 
0 1 2 3 4 5 6 7 8 9 10
No Pain

 

Pain as bad as you can imagine
4. Please rate your pain by selecting the one number that best describes your pain on the AVERAGE.
 
0 1 2 3 4 5 6 7 8 9 10
No Pain

 

Pain as bad as you can imagine
5. Please rate your pain by selecting the one number that tells how much pain you have RIGHT NOW.
 
0 1 2 3 4 5 6 7 8 9 10
No Pain

 

Pain as bad as you can imagine
6 Does your pain radiate from the area of maximum intensity, if so please describe from what area start to end
 
7. Select the one number that describes how, during the past 24 hours, pain has interfered with your:
A General Activity
 
0 1 2 3 4 5 6 7 8 9 10
Does not interfere

 

Completely interfers
B.  Mood
 
0 1 2 3 4 5 6 7 8 9 10
Does not interfere

 

Completely interfers
C. Walking Ability
 
0 1 2 3 4 5 6 7 8 9 10
Does not interfere

 

Completely interfers
D. Normal Work (both outside the home and Housework.)
 
0 1 2 3 4 5 6 7 8 9 10
Does not interfere

 

Completely interfers
E. Relations with other people
 
0 1 2 3 4 5 6 7 8 9 10
Does not interfere

 

Completely interfers
F. Sleep
 
0 1 2 3 4 5 6 7 8 9 10
Does not interfere

 

Completely interfers
G. Enjoyment of life
 
0 1 2 3 4 5 6 7 8 9 10
Does not interfere

 

Completely interfers

In addition to comparing the pain inventory to help your doctor better manage your pain please tell us:
What does your pain feel like? Select those words that describe your pain.

aching throbbing shooting stabbing nagging sharp
dull tender burning numb radiating squeezing
cramping deep                
How long have you had this pain?
Less than a week 1 to 2 weeks 2 to 4 weeks more than a month
What kinds of things make you pain feel better (for example, heat, medicine, rest)?
What kinds of things make your pain worse (for example, walking, standing, lifting)?
LIST PAIN MEDICATION(S) AND HOW OFTEN TAKEN (CURRENT)
ALLERGIES
OTHER CURRENT PAIN TREATMENTS MODALITIES
Do you have any other symptoms?
nausea vomiting constipation diarrhea lack of appetite indigestion difficulty sleeping    
feeling drowsey nightmares dizziness tiredness itching urinary/bowel problems sweating    
weakness headaches                        
COMMENTS: Write down any questions or information you need to share with your doctor, nurse, or pharmacist about your pain.
Does the patient have any of the following devices.
Intrathecal Pump Medtronics ANS SCS BMR-2000 none
Are they helpful or ineffective?


The Aquatic Therapy Center
700 South St. Mary's
Street @ Durango
San Antonio, TX 78205

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