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MEDICAL/FAMILY/SOCIAL HISTORY
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Past Medical History
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Past Medical History Freewrite
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Past Surgical History
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Comments
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Childhood illnesses
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Comments
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PCP
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PCP Contact Information
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Medical History of Mother/Father/Siblings/Children
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Comments
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Marital Status
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Living Arrangements
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Occupation
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Alcohol
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Comments
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Smoking/Tobacco Use
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How long have you used tobacco
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Other substances
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Have you done Physical Therapy?
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Did you do it for at least 6 weeks?
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Was it helpful longterm?
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Did it make your pain worse?
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Have you used anti-inflammatory medications in the past?
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Other medication not listed on selection
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Any of these provide significant relief?
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Any allergies to these medications?
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Have you used muscle relaxants in the past?
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Other medication not listed on selection
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Any of these provide significant relief?
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Any allergies to these medications?
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Have you used neuropathic medication in the past?
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Other medication not listed on selection
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Any of these provide significant relief?
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Any allergies to these medications?
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Have you used any opioid or narcotic medications in the past?
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Other medication not listed on selection
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Any of these provide significant relief?
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Any allergies to these medications?
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Have you ever been prescribed with Subuxone?
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Have you ever been prescribed Subutex?
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Have you ever been prescribed buprenorphine?
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Any of these provide significant relief?
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Any allergies to these medications?
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Which medication were you able to take?
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Current Pain Level
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Average Pain Level
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Worst Pain Level
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