Pain management center

NAME: _______________________________________________________________ Please fill in completely (0) all circles (yes and no) as pertaining to your current symptoms.
Allergy/Immune system
Male reproductive
Female reproductive
How long have you had your pain? O 0-6 months O 6-12 months O 1-5 years O 5-10 years O longer than 10 years In the last 2-3 weeks when does your pain occur? On a scale of 0 to 10, with 10 being the worst pain, mark where the severity of your pain is. O 0 Associated numbness O Yes O No Associated Tingling O Yes O No What was the setting when the problem first occured? O prolonged keyboard activity O repetitive grasping O sports (without obvious trauma) O squatting Please describe your pain (quality): O aching O penetrating O pins and needles O pressure Please indicate those activities that INCREASE your pain: (check all that apply) O work O foods or beverages O locale (i.e. home/work/etc.) O medications O menstrual cycle O physical activites O recreational drug use O sleep-related factors Please indicate those activities that DECREASE your pain: (check all that apply) O walking O emergency room treatment O elevating the affected area O non weight bearing O supporting the extremity O avoiding stress O language difficulty O mental status change How many ER visits have you had in the last 3 months for pain? Do you take any of the following anticoagulants? (check all that apply) Have you tried any of these therapies: O acupressure O nerve stimulation O occupational therapy Have you tried any of these pain clinic treatments: O injection therapy O medications O physical therapy Have you tried the following NSAIDS to help relieve your pain: O ibuprofen O aleve
Are you on Workers Comp?

Mark the appropriate information related to Worker's Compensation:
O unable to work at all since the injury O able to work with restrictions since the injury O temporary limitations after the injury
Litigation pending:
O Yes

If you are involved in any lawsuits, who is the lawsuit against? (Check all that apply)
O Worker's Compensation O Auto accident

Have you been to any of the following types of doctors?
O Back Surgeon

Past Medical History
Heart disease
Thyroid/endocrine problem O Yes O No
Family History
Is your father still alive?
Do you have children or other dependents at home? O Yes O No
Social History
What is your marital status?

Are you currently employed?
Are you on Disability?
What type of disability do you have?

Do you use alcohol to control your pain?
O Yes O No

Mark if you use any of the following drugs recreationally
O Amphetamines

Dependency or addiction to drugs now or in the past? (Check all that apply)
O Amphetamines
O Marijuana O Morphine O Oxycodone O Soma Please mark your pain area(s) on this diagram.


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A NEW Sexual Assault Referral Centre is set to open in North Wales. Feb 18 2009 Daily Post North Wales Police Authority has authorised the majority of the £700,000 funding for the centre which will open in Colwyn Bay. It will specialise in investigating sex crimes and providing support for victims. Detective Superintendent Alan Green, Head of the Force’s Public Protection Unit, said:

Aviva actions croissance 2011-03-31.xls

Forme juridique Objectif de gestion Le FCP a pour objectif d’obtenir une performance supérieure à celle de l’indicateur de référence pour optimiser le rendement de contratsd'assurance-vie libellés en unités de compte relevant de l'option dite "DSK". Date de création Catégorie Engine - EuroPerformance Performances * Cumulées Classification AMF

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