PAIN EVALUATION FORM Date:

Name:
Last First

Address:

Tel. #: Date of Birth Gender: Male Female

Age: Dominant Hand: Right Left Height: Weight:

1. Referring Dentist or Doctor:

Complete Name of Referring Doctor:
Last First

Complete Address
Phone

2 Current Dentist / Doctors

List the names and COMPLETE addresses of all health care practitioners you are currently seeing

NAME SPECIALTY

ADDRESS PHONE

NAME SPECIALTY

ADDRESS PHONE

It is the policy to forward copies of our medical report to you medical GP, Dentist and any other
specialists unless we are advised otherwise.

IMPORTANT NOTE:

It is the policy of this practice to request payment of fees for treatment provided, at the end of every visit. Any other
arrangements with regard to payment of account due, should be agreed prior to commencement of treatment.
I have read the above notice regarding the payment of treatment of fees and I undertake to abide by the conditions quoted
above.

Signed:

© Éamonn MurphyPS#1
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3. Understanding Your Complaint

A. Describe thoroughly in your own words the problem you would like help with:

B. How often does your pain occur? C. What is the duration of your pain? (Length it lasts)
 Continuous  None
 Several times a day  Seconds
 Once per day  Minutes
 Once per week  Hours
 Less than once per week  Days
 Never  Weeks
 Continuous

D. When is your pain worse?

 Morning
 Mid day
 Evening
 Nighttime

E. Circle a number below to indicate your current pain intensity over the past week

0 1 2 3 4 5 6 7 8 9 10
No pain Mild pain Moderate pain Severe pain

Most intense pain

F. Below is a list of words that may describe your pain. Please tick the word(s) that most closely describe your
imaginable
pain.
Throbbing Shooting Stabbing Sharp
Cramping Cramping Gnawing Hot Burning
Aching Heavy Tender Splitting
Tiring- Exhausting Sickening Fearful Punishing-Cruel

G. Please indicate clearly and comprehensively where you have pain:

Left
Right
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H. What makes the pain WORSE? Be Specific.

I. What makes the pain BETTER? Be Specific.

4. Effects of Pain

A. Circle the number to indicate how much your pain has interfered with your activities this past week

0 1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe
No Interference

B. Circle the number to indicate how distressed or bothered you have been in the past week about Complete
the pain Interference

0 1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe
None
The most
5. Current Medications
severe
List ALL medicines you are currently taking for medical and pain problems (including prescribed, over the
imaginable
counter, herbs, vitamins): (Write on the back of this sheet if necessary).
Name Pill Strength Number of times taken per day Doctor who prescribed

6. History of Your Pain

A. When did your pain start?
B. When did your pain become a problem?
C. What event or events lead to your present pain:
accident other injury other disease other
cancer no obvious cause following an operation

D. What do YOU think is the cause of your pain?

E. Is your pain getting better or worse? Be specific.

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7. Previous Doctors
List all doctors you have seen for your pain problem (continue on the back of the sheet if needed)
Date Name Specialty Address / Phone

8. X-rays and Tests

Please list in chronological order, all tests and x rays performed to evaluate your pain:
Date Test Result

9. Previous Treatments
Indicate which of the following treatments you have tried for your pain problem:

anti-inflammatory antidepressants acupuncture biofeedback

homeopathy chiropractor TENS narcotic painkillers
nerve blocks physiotherapy hypnosis relaxation training
exercise program traction psychotherapy other (list)

10. Previous Medications

List all previous pain medications you have taken for pain:
Name of medicine Dose Dates of use Helpful? Reason for stopping
YES / NO
YES / NO
11. Surgeries
List all previous hospitalisations, or injuries you have ever had:
Year Type of Surgery Hospital Doctor

12. Allergies
List all allergies to medications and the reaction you had to any medicine:
Medicine Reaction Medicine Reaction

13. Review of Systems

Please check if you have or had any of the following:
A. General headaches
weight loss visual changes
poor appetite mouth problems
severe fatigue / low energy thyroid problems
neck pain
B. Skin difficulty swallowing
rash
nail changes D. Haematological
bumps/nodules anemia
herpes easy bruising
bleeding problems
C. Head and Neck taking blood thinners
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sexual dysfunction
E. Cardiopulmonary
Shortness of breath H. Musculoskeletal
cough Arthritis Type:
exercise limitations osteoporosis
chest pain muscle pain
irregular heartbeat muscle wasting
heart murmurs fractures
high or low blood pressure
circulation problems Neurologic
ankle swelling numbness
weakness
falling or loss of balance
F. Gastrointestinal stroke
Abdominal pain seizures
Nausea or vomiting memory loss
Constipation or diarrhea
History of ulcers or heartburn J. Infections
measles
G. Genitourinary mumps
pregnant chicken pox
frequent or hesitant urination rheumatic fever
pain with urination hepatitis
blood in urine HIV / AIDS
incontinence
14. Past Medical Problems: Please indicate any other medical problems you have had.

15. Habit History

A. Smoking: Yes No Quit. Number per day Number of years smoked .
B. Alcohol Use: None Occasional Daily How much per week .
C. Recreational Drugs: Current Use? Yes No
D. Coffee / Tea / Caffeine: Number of cups per day
E. Clenching Teeth: Yes No
F. Grinding Teeth: Yes No
G. Do you wear an intra-oral splint (night guard)? Yes No
H. Do you chew gum? Yes No
I. Do you bite your nails? Yes No
J. Is anyone concerned about your use of alcohol, drugs, or medications? Yes No

16. Family History

Member Deceased or Living Age Medical Problems
1. Father

2. Mother
3. Brothers / Sisters
4. Children

Does anyone in your family suffer from TMJ / Facial Pain?

Is there a history of arthritis in your family?
Are you adopted? Yes No

17. Social History

A. Relationship Status:
Single Married Separated Widowed Divorced
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B. Employment Status:
Employed F/T Retired Are you on disability? Y / N
Employed P/T Unemployed due to pain Date disability started:
Self employed Unemployed due to other Reason for disability:
Homemaker reasons:
How long have you been

unemployed or retired?

C. Number of hours worked per week: Are you happy with your job?
Your current or most recent occupation

18. Financial History

Do you have any legal action pending related to this pain or any other health problem? Yes No

19. Psychological History

1. Describe your mood.

Do you have problems with any of the following:

concentration anxiety appetite motivation
depression sleep self-worth suicidal thoughts

2. Are you currently seeing a doctor for mood problems? Yes No

3. If Yes, Name Phone