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Pain History & Physical

This is a secure web form. Your information provided here will become part of your Bismarck Surgical Associates Medical Record and will be protected as such. Depending on timing the Nurse may ask you these questions during the phone interview. Please inform the Nurse you filled this form out on the Web so you do not have to repeat the same information.

**Only complete this form if you are having a Pain procedure. Surgical patients should use the "Surgical Pre op Form"

First and last name
Self referral or Who sent you to us?
List if you are the patient, relative or friend providing the information.


List reactions you have had with each, Indicate if you are Latex sensative


Indicate 'none' if you are not taking any medications. Please include the dosages, any over the counter pain medications, blood thinners-and the doctor who monitors the blood thinner.

Check the blood thinning medications you take:

Do you have or ever had:

Heart Problems

How long ago were your stents placed , how many stents do you have
What year did you have bypass surgery?
what kind of blood clots and when did you have them
list any other heart issues, irregular heart beat, valve problems, etc

Respiratory / lung problems

list any other lung or breathing issues not mentioned above, example: sleep apnea



list any other neurological issues, explain


list any other gastrointestinal issues, IBS, Crohns disease, etc


describe any recent bowel or bladder changes or write no change.


Indicate when you had shingles, or any other skin issues. Describe any sores that are not healing or history of MRSA.


Explain how long ago you had treatment or if you are currently being treated


Ears Nose Throat

Describe any problems with ears, nose or throat


Explain what kind of cancer or cancers you have or have had in the past

Family History:

Heart Disease

List which immediate family members have heart disease and what kind of problems, for example: father-heart attack, mother bypass, brother-high blood pressure, etc

Family Cancer / Cancer history

List which immediate family members have cancer and what type they have, for example: mother-lung, father-stomach,etc

Social History

please select closest match
Approximately how many packs per day do you smoke
How many years have you smoked
What year did you quit smoking

Any other Medical issues:

Explain any other medical issues we need to be aware of, so we can provide the best care possible.


Workers' Compensation Claim


Location of pain

Describe any other area of pain related to this appointment at BSA.
Describe the weakness, when did it start
Describe where you feel the numbness, when did it start

Rate your pain on a scale of 0(no pain) - 10 (worse pain ever)

0 means 'no pain' up to 10 which is the worst pain you have ever experienced in your life.
0 means 'no pain' up to 10 which is the worst pain you have ever experienced in your life.
0 means 'no pain' up to 10 which is the worst pain you have ever experienced in your life.
Indicate if you had any prior experiences with this type of pain and explain.

Describe the pain, check all that apply:

throbbing, prickling, tightness etc.

Is the pain constant?

When is the pain worse?

for example: ice packs, tried physical therapy, tried massage, tried chiropractor, medications, or any other things that work for you.
for example: standing for more than 5 minutes, bending forward, going up or down stairs, sitting, lying on one side or the other, looking upward, looking down, turning head from side to side, changing from a sitting to a standing position, etc
Indicated NONE if you never had injections before. EXPLAIN: who gave the injections, which areas they injected, approximately when they did the last injection, if you got relief and how long it lasted, etc.
Indicate approximately when you had the procedure, who did the procedure what level or levels they worked on, did you get relief, etc

Recent tests:

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