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What Brings You To The Clinic?
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Personal Injury/Pain (New Patient)
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Weight Loss (New Patient)
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Pain Management
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Mechanism of Injury
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Where exactly is your pain?
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What date did the incident occur?
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What was the event that caused your pain?
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Which ED did you report to? If you didn't go to the ER skip this and the next question
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Did you lose consciousness/ pass out/ faint?
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What did they do for you in the ED?
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What have you tried to relieve your pain?
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What is your pain level out of 10, without medication?
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How about with medication?
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How would you describe the pain?
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Does your pain radiate (travel from one area to another) Yes / No
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If it does radiate, where exactly does it radiate? If not go to the next question.
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How long does the pain last until you have to take medication?
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What makes your pain get worse?
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What is your pain relieved by, besides medication?
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When was the last time you took pain medication?
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PEG (pain, enjoyment, general) score
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From 0-10 how do you best describe your pain in the PAST WEEK?
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From 0– 10, how the pain has interfered with their enjoyment of life? (0 = “not at all”, 10 = “complete interference”)
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From 0– 10 how has the pain interfered with your general activity? (0 = “not at all”, 10 = “complete interference”)
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Patient Centered Goals For Treatment:
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Which of these activities does the pain hinder, but you want/need to improve?
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How long (in minutes) can you do this activity right now?
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How long (min) would you like to do this activity for (just enter a number in minutes that will enhance your quality of life)?
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Weight Loss
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We like to approach weight loss from 3 different angles: Diet, Exercise an External factors like sleep hygiene, pmh like insulin
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resistance, hypothyroidism, uncontrolled htn, DMII or some condition that affects your sleep, response to certain kinds of food
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Which ones do you believe affect you the most
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How long have you believed you had a weight issue?
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What have you tried to overcome it?
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What is your ideal weight?
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When was the last time you were that weight?
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Diet
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Do you typically eat breakfast Yes / No
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If yes, What kind of foods do you typically eat?
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Typical Lunch?
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Typical Dinner?
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Do you snack in between meals?
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If so, what type of snacks do you usually eat in between meals? If not skip the next question
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Do you eat a lot of fruits and vegetables? Yes or No
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How many cups of water do you drink per day?
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How many sodas or other sugary drinks do you consume per day?
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How many cups of Caffeine do you consume per day?
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Exercise
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Do you exercise regularly? Yes / No
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If you do exercise regularly, which one best describes your exercise?
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Sleep Hygiene
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About how many hours do you sleep at night?
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Do you feel refreshed when you wake up? Yes / No
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Past Surgical History
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Past Surgical History
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Past Medical History
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Past Medical History
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Family History
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Family history
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Social History
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Alcohol
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Do you us Illicit drugs like marijuana or stronger? Yes / No
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