Patrick B. Wood, M.D.
FOR OFFICE USE ONLY
161 River Oaks Drive y Canton, MS 39046
Phone: (601)855-4810 y Fax: (601) 855-4313
PHYSICIAN NOTES
MROMC1331
8742720
(1)
FOR OFFICE USE ONLY
Pain
How severe is your pain most of the time?
None
Minimal
Mild
How would you describe your usual pain?
Flu-like ache, primarily in the muscles
Deep ache, bone pain
Cramping or tightness
Other (describe):
PHYSICIAN NOTES
Moderate
Severe
Extreme
Tenderness to palpation
Severe sensitivity to light touch
Burning sensations
How often do you get painful flare-ups?
Rarely
Infrequently
Frequently
How severe are your pain flares usually?
Please answer the following either yes or no
Mild
Moderate
Severe
Yes No
Do you have pain when you sitting still or not doing anything?
If yes, does the pain go away when you move around?
Does your pain get worse especially at night?
Does your pain get especially bad after exerting yourself, e.g. walking, gardening?
Does your pain get worse when you tilt your head back or extend your neck?
Please shade in the areas of your usual pain on the diagram below and indicate the 3
most painful areas (i.e. #1. #2, #3).
(2)
Goals and Objectives:
What are your main goals/objectives for seeking help with this problem? What do you hope to
get from a treatment program?
1.
2.
What sorts of things make your pain worse?
Emotional distress
Worrying
Family Conflicts
Personal conflicts
Chemical exposures
Medication side effects
Physical injuries
Problems with sleep
Cold
Heat
Weather changes
Extending my neck
Physical inactivity
Light to moderate activity
Car travel
Airplane travel
Other (describe):
Mental stress
Perfectionism
Allergies
Infections
Humidity
Sitting still too long
Strenuous activity/exercise
Time zone changes
3.
In what ways do you foresee your life will change once you have met these goals?
Signature
Date
(18)
What sorts of things make your pain better?
Quality time with family/friends
Volunteer work
Resting/Relaxation
Distraction (e.g. reading, watching TV etc.)
Non-aerobic exercise (e.g. Yoga, Tai Chi)
Stretching
Running or jogging
Hypnosis
Massage/reflexology
Aromatherapy
Prescription pain medications
Prescription sleep medications
Prescription antidepressants
Pool therapy
Heat modalities (e.g. warm water, hot packs)
Chiropractic manipulation
TENS unit
Other (describe):
(3)
Social activities (e.g. clubs, church)
Counseling (e.g. psychologist, pastor)
Prayer/meditation
Getting enough sleep
Aerobic exercise (e.g. Pilates, Tai-Bo)
Walking
Strength training
Acupuncture
Biofeedback
Energy healing (e.g. Reiki)
Over-the-counter pain medications
Over-the-counter sleep medications
Nutritional supplements
Physical therapy
Cold therapy (e.g. ice packs)
Trigger point injections
Cranial Electrical Stimulation (e.g. Alpha-Stim)
Sleep
Developmental History
____________________
How long does it usually take you to fall asleep without medication?
____
What time do you typically go to bed?
AM
PM
____
What time do you typically wake up?
AM
PM
____ hours/night
About how many hours per night do you usually sleep?
How many times do you typically wake up to urinate? (circle)
0-1
2-3 4-5
6+
How many times do you wake up other than to urinate? (circle)
0-1
2-3 4-5
6+
Sleep-related symptoms
Yes
No
Do you dream or have nightmares?
Do you usually remember your dreams?
Do you get restorative/refreshing sleep?
Do your legs feel "restless or jittery" in the evening?
Does your bed partner say you kick your legs while asleep?
Do you grind your teeth at night?
Have you ever had a problem with sleep walking or unusual night-time activity?
Does your bed partner say you snore a lot?
Do you have acid reflux at night?
Do you sometimes stop breathing when you snore?
Do you ever awaken gagging or fighting for air?
Do you usually awaken with a headache?
Can you easily fall asleep in the afternoon?
Have you ever had a sleep study?
Please indicate if during your birth or childhood you had any of the following problems:
Maternal illness during pregnancy
Problem with delivery/obstetrical complications
Premature delivery
NICU stay
Bed-wetting after age 5
Learning disability
Dyslexia
Attention deficit disorder (ADD/ADHD)
Growing pains
Chronic abdominal pain or constipation
Frequent ear/nose/throat infections
Asthma
Please indicate if during your childhood/adolescence you experienced any of the following:
Death of parent(s)
Divorce of parents
Single parent
Adoption
Foster parenting
Frequent moves
Distant/cold parenting style
Alcoholic parent
Abuse: neglect
Abuse: physical*
Abuse: emotional*
Abuse: sexual*
If any items checked: have you received counseling or therapy for these issues?
Yes No
If yes, please describe:
• If yes, were you diagnosed with sleep apnea?
• When was the date of you last sleep study? (mm/dd/yy)
/
/
When did you last get a good night’s sleep? _____ (years) or ______(months) or _____ (days)
* We understand that issues of child abuse may be highly sensitive; however, being aware of any history of abuse
may play an important role in understanding symptoms and the best means by which to address them.
Social History
Marital Status:
Single
Married
Divorced
Occupation:
Work Status:
Full Part-Time Unemployed
ti
Other (describe):
Habits:
Past Current Describe:
Never
Slight
Moderate
High
Sitting, inactive in a public place (e.g. theater, meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Do you participate in any form of regular exercise? Yes No
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
Activity:
Watching TV
• If yes, please describe:
Score_______
(4)
Disabled
Retired
Effect on Symptoms
Worse
No Effect
Better
Alcohol
Tobacco
Caffeine
Marijuana
Cocaine
Amphetamines
Hallucinogens
Complete the following by indicating your chance of dozing off to sleep during the listed activities.
Widowed No. of Marriages: _____
(17)
Family History
Relationship
Father:
Age
Living / Deceased Diagnosis / Problems
Mother:
Siblings:
Children:
Do you have a family history of any of the following diseases? If so, please specify which relative:
Fatigue
Are you bothered by chronic fatigue?
Yes No
If yes, approximately when did you first begin to experience fatigue? Month/Year
How bad would you say your fatigue is on average?
Minimal
Mild
Moderate
Severe
Extreme
Is your fatigue constant or does it wax and wane?
Constant
Intermittent
Which statement(s) best describe your daily energy patterns?
My best energy of the day is usually in the (check one):
morning afternoon evening
My worst energy of the day is typically in the (check one): morning afternoon evening
Check all that apply:
I often get a burst of energy after a light meal or snack
I often get my ‘second wind’ fairly late at night.
I am exhausted after exertion and find it very hard to recover.
I am always tired and never have any energy.
What sorts of things make your fatigue worse?
Fibromyalgia:_______________________________________________________________________________
Other Chronic Pain condition (specify): __________________________________________________________
Chronic Fatique Syndrome: ___________________________________________________________________
What sorts of things make your fatigue better?
Attention Deficit-Hyperactivity Disorder (ADD/ADHD):________________________________________________
Parkinson’s Disease: _________________________________________________________________________
Multiple Sclerosis: ___________________________________________________________________________
Has your weight been stable over the last 6 months?
Alcohol Abuse/Dependence: ___________________________________________________________________
Drug Addiction: _____________________________________________________________________________
List your five most troublesome symptoms, from worst to least:
Depression: ________________________________________________________________________________
Bipolar Disorder (‘manic-depression’): ____________________________________________________________
Schizophrenia: ______________________________________________________________________________
Other mental illness (specify): __________________________________________________________________
Yes
No-gained______ lbs.
No-lost _______ lbs.
1.
2.
Notes – for office use only
3.
4.
5.
(16)
(5)
Review of Systems – Check each symptom to indicate the degree to which it affects you.
General
• Widespread pain or "hurting all over”
• Flu-like achiness
• Tenderness to palpation or pressure
• Skin sensitivity to light touch/stroke
• Deep ache/bone pain
• Burning sensations
• Chronic fatigue or “tired all the time”
• Difficulty recovering after exertion
• Trouble falling asleep
• Trouble staying asleep
• Waking up feeling tired
• Night Sweats
Eyes & Vision
• Dry or scratchy eyes
• Sensitivity to bright lights
• Blurred vision or trouble focusing eyes
• Difficulty seeing at night
• Double vision
• Excessive tearing or watery eyes
Ears, Nose & Throat
• Ringing in the ears (tinnitus)
• Sensitivity to loud noises
• Sinus congestion or stuffiness
• Sinus pain
• Trouble with taste or smell
• Dry mouth
• Frequent sore throats or painful glands
• Painful or bleeding gums
• Difficulty swallowing
• Lump in throat
• Jaw pain, painful chewing or “TMJ”
• Grind teeth or clench jaws
Heart & Lungs
• Fast or irregular heartbeat (palpitations)
• Feeling dizzy or ‘goofy’ after standing
• Short of breath/unable to get deep breath
Gastrointestinal
•
•
•
•
•
•
•
Heartburn or reflux
Sick to the stomach (nausea) or vomiting.
Feeling bloated after a meal
Cramping or colicky abdominal pain
Diarrhea
Constipation
Excessive wind or gas (flatus)
None
None
None
None
None
Minimal
Minimal
Minimal
Minimal
Minimal
(6)
Mild
Mild
Mild
Mild
Mild
Moderate
Moderate
Moderate
Moderate
Moderate
Severe
Severe
Severe
Severe
Severe
Male Hormonal Issues (male only)
Extreme
Extreme
Extreme
Extreme
Extreme
Please answer each of following by checking the appropriate box.
Yes
No
2. Do you have a lack of energy?
3. Do you have a decrease in strength and/or endurance?
4. Do you have lost height?
5. Have you noticed a decreased "enjoyment of life"?
6. Are you sad and/or grumpy?
7. Are your erections less strong?
8. Have you noticed a recent deterioration in your ability to play sports?
9. Are you falling asleep after dinner?
10. Has there been a recent deterioration in your performance at work?
1. Do you have a decrease in libido (sex drive)?
Score_______
i.vii.3x
Please indicate if you have/have had any of the following:
Erectile dysfunction
Impotence
Breast pain/tenderness
Difficulty with urination
Prostatitis
Enlarged breasts (gynecomastia)
Infertility
Elevated PSA
Breast cancer
Venereal disease
Blood in urine (hematuria)
Testicle pain (testalgia)
Prostate cancer
Testicular cancer
Family hx of prostate cancer
Have you ever or are you currently using testosterone or DHEA supplements?
No
Yes, past
Yes, currently
(15)
Review of Systems (continued)
Gynecological History (female only)
How old were you when you first started having menstrual cycles/periods:
years old
Current menstrual status (check one):
Still menstruating
Partial Hysterectomy
Perimenopausal
Natural menopause
Date of surgery: ____________
Reason for surgery:___________
Complete Hysterectomy
Date of surgery: ____________
Reason for surgery:___________
Date of last menstrual period: _____________
During your regular cycles, do/did you have problems with the following (check all that apply):
Cramping
Bloating
Retaining fluid/swelling
Heavy bleeding
Breast tenderness
Abdominal/pelvic pain
Headaches
Mood swings
Tearfulness
Depression
Irritability
Rage episodes
When do/did these symptoms typically occur in relation to your periods?
before
during
after
In your opinion, do your menstrual cycles affect your overall symptoms of fibromyalgia?
If yes, please describe:
Yes
No
Are you now or have you ever used fertility treatments, hormone therapy or birth control?
If yes, describe and give dates:
Yes
No
Please check any of the following that apply to your situation (give dates of onset/diagnosis):
Infertility/difficulty conceiving
Polycystic ovary syndrome (PCOS)
Miscarriage(s)
Abortion(s)
C-section
Tubal ligation (“tubes tied”)
Fibroid tumors
Premenstrual syndrome (PMS)
Endometriosis
Chronic pelvic pain
Decreased libido
Abnormal uterine bleeding
Breast pain (mastalgia)
Fibrocystic breasts
Breast biopsy
Milky breast discharge (galactorrhea)
Breast implants
Breast reduction
Pelvic inflammatory disease
Frequent yeast infections
Laparoscopic surgery
Dilation & Curettage (D&C)
Abnormal Pap smear
Colposcopy
Cancer: breast
Cancer: cervical
Cancer: uterus
Cancer: ovarian
Feel free to comment on or clarify any of the above:
(14)
Bladder
• Leaking urine (incontinence)
• Over-active bladder (urgency)
• Difficulty starting the flow of urine
• Trouble completely emptying bladder
• Burning/aching bladder
• Pain when urinating
Musculoskeletal
• Stiffness
• Joint pains
• Decreased muscle strength
• Decreased muscle endurance
• Feeling tight or “need to stretch”
• Muscle spasms
• Leg cramps at night
• Swelling in hands, arms, legs or feet
Endocrine
• Difficulty losing weight
• Weight gain
• Weight loss
• Crave sweets
• Crave chocolate
• Crave salt
•
•
•
•
•
Hypoglycemia/low blood sugar
Low sex drive/decreased libido
Sensitivity to cold exposure
Sensitivity to heat or humidity
Cold hands or feet
Skin
• Coarse, dry skin
• Increased perspiration
• Decreased perspiration
• Easy bruising
• Thinning/fragile skin
• Widespread itching
• Rashes
Neurological
• Headaches – tension or migraine
• Restless legs at night or when resting
• Numbness or tingling sensations
• Dizziness/Vertigo
• Clumsiness or lack of coordination
• Bumping into things (e.g. door frames)
• Stumbling/Falling
None
None
None
None
None
Minimal
Minimal
Minimal
Minimal
Minimal
(7)
Mild
Mild
Mild
Mild
Mild
Moderate
Moderate
Moderate
Moderate
Moderate
Severe
Severe
Severe
Severe
Severe
Extreme
Extreme
Extreme
Extreme
Extreme
Review of Systems (continued)
Cognition & Mood
• Difficulty with concentration
• Problems with memory
• Problems staying focused
• Problems multi-tasking
• Difficulty expressing yourself
• Problems perceiving clearly
• Difficulty with mental speed
• Feelings of ‘spaciness’
• Feelings of haziness
• Problems with confusion / disorientation
• Cluttered thinking
• Feeling foggy
• Rushing thoughts
• Fuzzy headedness
• Problems with “information overload”
• Feeling depressed, blue or hopeless
• Feeling anxious, worried or stressed out
• Feeling angry or irritable
• Feeling apathetic, empty or "blah"
• Feeling restless
None
Minimal
Mild
Moderate Severe Extreme
Please list any other medications / supplements you have previously tried to help with your symptoms along
with their benefits and/or side effects:
Medication / Supplement
Benefits / Side Effects – Why did you stop using?
Please review the items below and check the answer that best describes how often each item has applied
to you over the past 6 months.
Never
Rarely
Sometimes
Often
Very often
Trouble wrapping up the final details of a
project once the challenging parts are done.
Difficulty getting things in order when you have
to do a task that requires organization.
Problems remembering appointments or
obligations.
Avoiding or delaying tasks that require a lot of
thought.
Fidgeting or squirming with your hands or feet
when you have to sit down for a long time.
Feel restless, overly active or compelled to do
things, like you were driven by a motor.
(13)
(8)
MEDICATION HISTORY
Emotional Problem Checklist (please check yes or no to each of the following):
Please list ALL medications you are currently taking, including hormones, birth control and supplements
Have you been feeling down, depressed or hopeless in the past month?
Name
Are you bothered by little interest or pleasure in doing things?
Strength
Schedule / Frequency
Indication (why do you take this?)
Has your appetite changed (eating more or eating less)?
Has your sleep been disturbed (insomnia or over-sleeping)?
Do you feel worthless or guilty?
Do you worry about a lot of different things?
Do you often feel tense, worried or ‘stressed out’?
Do you have sudden or unexpected bouts of anxiety or nervousness?
Do you have sudden onset of symptoms of palpitations, shortness of breath, or trembling?
Do you avoid places or situations because of anxiety or worry?
Do you have recurrent, persistent or unwanted thoughts or do repetitive behaviors?
In your lifetime, have you faced any potentially life-threatening events such as natural disaster,
serious accident, physical or sexual assault, military combat or child abuse?
If yes, since you experienced any of these stressors, have you been…
...easily startled?
...angry or irritable?
...emotionally numb or detached from your feelings?
...prone to physical reactions (e.g. heart racing, sweaty palms) when reminded of the event?
Yes
No
Has there ever been a period of time when you were not your usual self and you...
...felt so good or hyper that people thought you were not your normal self?
...were so irritable that you shouted at people or started fights or arguments?
...felt much more self-confident than usual?
...got much less sleep than usual and found you didn’t really miss it?
...were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...were so easily distracted by things that you had trouble concentrating/staying on track?
...had much more energy than usual?
...were much more active or did many more things than usual?
...were more outgoing than usual, for example, you called friends in the middle of the night?
Drug allergies / adverse reactions:
...were much more interested in sex than usual?
...did things that other people might have thought were excessive, foolish, or risky?
...spent money that got you or your family into trouble?
Which medications have you found to be most helpful for treating your symptoms of. . .
If YES to more than one of the above, have several of these happened during the same period?
Do you drink alcohol?
Do you use prescription medicines or street drugs to relax, calm your nerves, or get high?
Pain:
Have you ever made an effort to cut down on your drinking or drug use?
Fatique:
Have you ever been annoyed by people who criticize your drinking or drug use?
Insomnia:
Do you ever feel guilty about your drinking or drug use?
Do you ever drink/use drugs to steady your nerves, treat a hangover or prevent withdrawals?
Do you feel that your eating is out of control?
(12)
(9)
Medical History
Medical History – continued
Current/Previous medical diagnoses - check all that apply:
Eyes, Ears, Nose & Throat
Glaucoma
Hay fever/seasonal allergies
Sinus problems
Tinnitus
Cardiovascular
Angina/Heart disease
Congestive heart failure (CHF)
Heart murmur
High blood pressure
Peripheral vascular disease
Postural orthostatic tachycardia
Rheumatic heart disease
Thrombophlebitis
Pulmonary
Asthma
Emphysema/COPD
Sarcoidosis
Sleep Apnea (OSA)
Gastrointestinal
Chrohn’s disease/Ulcerative Col.
Gluten intolerance (Celiac)
Fatty liver disease (NASH)
Gall stones
Hepatitis
Irritable bowel syndrome
Proctalgia fugax (anal spasms)
Reflux/heartburn (GERD)
Genitourinary
Frequent bladder infections
Incontinence – stress
Interstitial cystitis
Kidney stones
Endocrine
Adrenal insufficiency
‘Borderline’ diabetes
High cholesterol
Hyperthyroid / Hypothyroid
Rheumatologic
Ankylosing spondylitis
Arthritis/degenerative joint dis.
Osteoporosis/osteopenia
Polymyalgia rheumatica
Rheumatoid arthritis
Systemic lupus erythematosus
Musculoskeletal/Orthopedic
Carpal tunnel syndrome
Ehlers-Danlos Syndrome
Herniated disc: neck
Herniated disc: upper back
Joint hypermobility syndrome
Low back pain (chronic)
Rotator cuff injury/tear
Sciatica
Spinal stenosis
Tendonitis
Neurological
Cervical stenosis/myelopathy
Chiari syndrome
Headaches – cluster
Headaches – migraine
Restless Legs Syndrome
Parkinson’s disease
Peripheral neuropathy
CRPS/RSD
Stroke (CVA/TIA)
Thoracic outlet syndrome
Tic disorder
Trigeminal neuralgia
* CONTINUED ON NEXT PAGE *
Notes – for office use only
(10)
Meniere's disease
“TMJ” disorder
Deep vein thrombosis (DVT)
Mitral valve prolapse
Raynaud’s syndrome
Restrictive lung dis. (fibrosis)
Dermatology
Acne
Psoriasis
Blood disorders
Anemia, iron deficiency
Clotting disorder – specify:
Dandruff
Rosacea
Eczema/Atopic dermatitis
Urticaria (Hives)
Lead poisoning
Sickle cell anemia
Cancer
Specify type(s):
Other – please list:
Diverticulitis
Hemorrhoids
Primary biliary cirrhosis
Incontinence – urge
Diabetes
Gout
Psoriatic arthritis
Frozen shoulder
Herniated disc: lumbar spine
Plantar fasciitis
Scoliosis
Chronic whiplash
Headaches – tension
Multiple sclerosis
Seizure disorder/epilepsy
Tremor – benign/familial
Surgical History
Please indicate if you have had any of the following surgeries and the year they were performed:
Appendectomy
Carpal tunnel
Gallbladder
Gastropexy / Gastric by-pass
Hernia repair
Joint replacement
Sinus surgery
Spinal surgery/fusion - neck
Spinal surgery/fusion – back
Tonsillectomy
Uvulopalatopharyngoplasty (UPPP) Other – please describe:
Psychiatric History
Please check if you have ever been diagnosed with or treated for any of the following:
Depression
Dysthymia
Bipolar Disorder
Anxiety, generalized
Post-traumatic stress disorder
Panic Disorder
Seasonal Affective Disorder
Premenstrual Dysph. Disorder Post-partum Depression
Social Anxiety Disorder
Attention Deficit Disorder (ADHD) Obsessive-Compulsive
Anorexia nervosa
Alcohol Dependence
Bulimia (Binge & Purge)
Drug addiction/Dependence
Borderline Personality Disorder
Compulsive Gambling
Other – please specify:
Do you currently attend any type of counseling or therapy? Yes No
Have you ever been hospitalized for psychiatric reasons?
Notes – for office use only
(11)
Yes No
If yes, how many times: _______
Medical History
Medical History – continued
Current/Previous medical diagnoses - check all that apply:
Eyes, Ears, Nose & Throat
Glaucoma
Hay fever/seasonal allergies
Sinus problems
Tinnitus
Cardiovascular
Angina/Heart disease
Congestive heart failure (CHF)
Heart murmur
High blood pressure
Peripheral vascular disease
Postural orthostatic tachycardia
Rheumatic heart disease
Thrombophlebitis
Pulmonary
Asthma
Emphysema/COPD
Sarcoidosis
Sleep Apnea (OSA)
Gastrointestinal
Chrohn’s disease/Ulcerative Col.
Gluten intolerance (Celiac)
Fatty liver disease (NASH)
Gall stones
Hepatitis
Irritable bowel syndrome
Proctalgia fugax (anal spasms)
Reflux/heartburn (GERD)
Genitourinary
Frequent bladder infections
Incontinence – stress
Interstitial cystitis
Kidney stones
Endocrine
Adrenal insufficiency
‘Borderline’ diabetes
High cholesterol
Hyperthyroid / Hypothyroid
Rheumatologic
Ankylosing spondylitis
Arthritis/degenerative joint dis.
Osteoporosis/osteopenia
Polymyalgia rheumatica
Rheumatoid arthritis
Systemic lupus erythematosus
Musculoskeletal/Orthopedic
Carpal tunnel syndrome
Ehlers-Danlos Syndrome
Herniated disc: neck
Herniated disc: upper back
Joint hypermobility syndrome
Low back pain (chronic)
Rotator cuff injury/tear
Sciatica
Spinal stenosis
Tendonitis
Neurological
Cervical stenosis/myelopathy
Chiari syndrome
Headaches – cluster
Headaches – migraine
Restless Legs Syndrome
Parkinson’s disease
Peripheral neuropathy
CRPS/RSD
Stroke (CVA/TIA)
Thoracic outlet syndrome
Tic disorder
Trigeminal neuralgia
* CONTINUED ON NEXT PAGE *
Notes – for office use only
(10)
Meniere's disease
“TMJ” disorder
Deep vein thrombosis (DVT)
Mitral valve prolapse
Raynaud’s syndrome
Restrictive lung dis. (fibrosis)
Dermatology
Acne
Psoriasis
Blood disorders
Anemia, iron deficiency
Clotting disorder – specify:
Dandruff
Rosacea
Eczema/Atopic dermatitis
Urticaria (Hives)
Lead poisoning
Sickle cell anemia
Cancer
Specify type(s):
Other – please list:
Diverticulitis
Hemorrhoids
Primary biliary cirrhosis
Incontinence – urge
Diabetes
Gout
Psoriatic arthritis
Frozen shoulder
Herniated disc: lumbar spine
Plantar fasciitis
Scoliosis
Chronic whiplash
Headaches – tension
Multiple sclerosis
Seizure disorder/epilepsy
Tremor – benign/familial
Surgical History
Please indicate if you have had any of the following surgeries and the year they were performed:
Appendectomy
Carpal tunnel
Gallbladder
Gastropexy / Gastric by-pass
Hernia repair
Joint replacement
Sinus surgery
Spinal surgery/fusion - neck
Spinal surgery/fusion – back
Tonsillectomy
Uvulopalatopharyngoplasty (UPPP) Other – please describe:
Psychiatric History
Please check if you have ever been diagnosed with or treated for any of the following:
Depression
Dysthymia
Bipolar Disorder
Anxiety, generalized
Post-traumatic stress disorder
Panic Disorder
Seasonal Affective Disorder
Premenstrual Dysph. Disorder Post-partum Depression
Social Anxiety Disorder
Attention Deficit Disorder (ADHD) Obsessive-Compulsive
Anorexia nervosa
Alcohol Dependence
Bulimia (Binge & Purge)
Drug addiction/Dependence
Borderline Personality Disorder
Compulsive Gambling
Other – please specify:
Do you currently attend any type of counseling or therapy? Yes No
Have you ever been hospitalized for psychiatric reasons?
Notes – for office use only
(11)
Yes No
If yes, how many times: _______
MEDICATION HISTORY
Emotional Problem Checklist (please check yes or no to each of the following):
Please list ALL medications you are currently taking, including hormones, birth control and supplements
Have you been feeling down, depressed or hopeless in the past month?
Name
Are you bothered by little interest or pleasure in doing things?
Strength
Schedule / Frequency
Indication (why do you take this?)
Has your appetite changed (eating more or eating less)?
Has your sleep been disturbed (insomnia or over-sleeping)?
Do you feel worthless or guilty?
Do you worry about a lot of different things?
Do you often feel tense, worried or ‘stressed out’?
Do you have sudden or unexpected bouts of anxiety or nervousness?
Do you have sudden onset of symptoms of palpitations, shortness of breath, or trembling?
Do you avoid places or situations because of anxiety or worry?
Do you have recurrent, persistent or unwanted thoughts or do repetitive behaviors?
In your lifetime, have you faced any potentially life-threatening events such as natural disaster,
serious accident, physical or sexual assault, military combat or child abuse?
If yes, since you experienced any of these stressors, have you been…
...easily startled?
...angry or irritable?
...emotionally numb or detached from your feelings?
...prone to physical reactions (e.g. heart racing, sweaty palms) when reminded of the event?
Yes
No
Has there ever been a period of time when you were not your usual self and you...
...felt so good or hyper that people thought you were not your normal self?
...were so irritable that you shouted at people or started fights or arguments?
...felt much more self-confident than usual?
...got much less sleep than usual and found you didn’t really miss it?
...were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...were so easily distracted by things that you had trouble concentrating/staying on track?
...had much more energy than usual?
...were much more active or did many more things than usual?
...were more outgoing than usual, for example, you called friends in the middle of the night?
Drug allergies / adverse reactions:
...were much more interested in sex than usual?
...did things that other people might have thought were excessive, foolish, or risky?
...spent money that got you or your family into trouble?
Which medications have you found to be most helpful for treating your symptoms of. . .
If YES to more than one of the above, have several of these happened during the same period?
Do you drink alcohol?
Do you use prescription medicines or street drugs to relax, calm your nerves, or get high?
Pain:
Have you ever made an effort to cut down on your drinking or drug use?
Fatique:
Have you ever been annoyed by people who criticize your drinking or drug use?
Insomnia:
Do you ever feel guilty about your drinking or drug use?
Do you ever drink/use drugs to steady your nerves, treat a hangover or prevent withdrawals?
Do you feel that your eating is out of control?
(12)
(9)
Review of Systems (continued)
Cognition & Mood
• Difficulty with concentration
• Problems with memory
• Problems staying focused
• Problems multi-tasking
• Difficulty expressing yourself
• Problems perceiving clearly
• Difficulty with mental speed
• Feelings of ‘spaciness’
• Feelings of haziness
• Problems with confusion / disorientation
• Cluttered thinking
• Feeling foggy
• Rushing thoughts
• Fuzzy headedness
• Problems with “information overload”
• Feeling depressed, blue or hopeless
• Feeling anxious, worried or stressed out
• Feeling angry or irritable
• Feeling apathetic, empty or "blah"
• Feeling restless
None
Minimal
Mild
Moderate Severe Extreme
Please list any other medications / supplements you have previously tried to help with your symptoms along
with their benefits and/or side effects:
Medication / Supplement
Benefits / Side Effects – Why did you stop using?
Please review the items below and check the answer that best describes how often each item has applied
to you over the past 6 months.
Never
Rarely
Sometimes
Often
Very often
Trouble wrapping up the final details of a
project once the challenging parts are done.
Difficulty getting things in order when you have
to do a task that requires organization.
Problems remembering appointments or
obligations.
Avoiding or delaying tasks that require a lot of
thought.
Fidgeting or squirming with your hands or feet
when you have to sit down for a long time.
Feel restless, overly active or compelled to do
things, like you were driven by a motor.
(13)
(8)
Review of Systems (continued)
Gynecological History (female only)
How old were you when you first started having menstrual cycles/periods:
years old
Current menstrual status (check one):
Still menstruating
Partial Hysterectomy
Perimenopausal
Natural menopause
Date of surgery: ____________
Reason for surgery:___________
Complete Hysterectomy
Date of surgery: ____________
Reason for surgery:___________
Date of last menstrual period: _____________
During your regular cycles, do/did you have problems with the following (check all that apply):
Cramping
Bloating
Retaining fluid/swelling
Heavy bleeding
Breast tenderness
Abdominal/pelvic pain
Headaches
Mood swings
Tearfulness
Depression
Irritability
Rage episodes
When do/did these symptoms typically occur in relation to your periods?
before
during
after
In your opinion, do your menstrual cycles affect your overall symptoms of fibromyalgia?
If yes, please describe:
Yes
No
Are you now or have you ever used fertility treatments, hormone therapy or birth control?
If yes, describe and give dates:
Yes
No
Please check any of the following that apply to your situation (give dates of onset/diagnosis):
Infertility/difficulty conceiving
Polycystic ovary syndrome (PCOS)
Miscarriage(s)
Abortion(s)
C-section
Tubal ligation (“tubes tied”)
Fibroid tumors
Premenstrual syndrome (PMS)
Endometriosis
Chronic pelvic pain
Decreased libido
Abnormal uterine bleeding
Breast pain (mastalgia)
Fibrocystic breasts
Breast biopsy
Milky breast discharge (galactorrhea)
Breast implants
Breast reduction
Pelvic inflammatory disease
Frequent yeast infections
Laparoscopic surgery
Dilation & Curettage (D&C)
Abnormal Pap smear
Colposcopy
Cancer: breast
Cancer: cervical
Cancer: uterus
Cancer: ovarian
Feel free to comment on or clarify any of the above:
(14)
Bladder
• Leaking urine (incontinence)
• Over-active bladder (urgency)
• Difficulty starting the flow of urine
• Trouble completely emptying bladder
• Burning/aching bladder
• Pain when urinating
Musculoskeletal
• Stiffness
• Joint pains
• Decreased muscle strength
• Decreased muscle endurance
• Feeling tight or “need to stretch”
• Muscle spasms
• Leg cramps at night
• Swelling in hands, arms, legs or feet
Endocrine
• Difficulty losing weight
• Weight gain
• Weight loss
• Crave sweets
• Crave chocolate
• Crave salt
•
•
•
•
•
Hypoglycemia/low blood sugar
Low sex drive/decreased libido
Sensitivity to cold exposure
Sensitivity to heat or humidity
Cold hands or feet
Skin
• Coarse, dry skin
• Increased perspiration
• Decreased perspiration
• Easy bruising
• Thinning/fragile skin
• Widespread itching
• Rashes
Neurological
• Headaches – tension or migraine
• Restless legs at night or when resting
• Numbness or tingling sensations
• Dizziness/Vertigo
• Clumsiness or lack of coordination
• Bumping into things (e.g. door frames)
• Stumbling/Falling
None
None
None
None
None
Minimal
Minimal
Minimal
Minimal
Minimal
(7)
Mild
Mild
Mild
Mild
Mild
Moderate
Moderate
Moderate
Moderate
Moderate
Severe
Severe
Severe
Severe
Severe
Extreme
Extreme
Extreme
Extreme
Extreme
Review of Systems – Check each symptom to indicate the degree to which it affects you.
General
• Widespread pain or "hurting all over”
• Flu-like achiness
• Tenderness to palpation or pressure
• Skin sensitivity to light touch/stroke
• Deep ache/bone pain
• Burning sensations
• Chronic fatigue or “tired all the time”
• Difficulty recovering after exertion
• Trouble falling asleep
• Trouble staying asleep
• Waking up feeling tired
• Night Sweats
Eyes & Vision
• Dry or scratchy eyes
• Sensitivity to bright lights
• Blurred vision or trouble focusing eyes
• Difficulty seeing at night
• Double vision
• Excessive tearing or watery eyes
Ears, Nose & Throat
• Ringing in the ears (tinnitus)
• Sensitivity to loud noises
• Sinus congestion or stuffiness
• Sinus pain
• Trouble with taste or smell
• Dry mouth
• Frequent sore throats or painful glands
• Painful or bleeding gums
• Difficulty swallowing
• Lump in throat
• Jaw pain, painful chewing or “TMJ”
• Grind teeth or clench jaws
Heart & Lungs
• Fast or irregular heartbeat (palpitations)
• Feeling dizzy or ‘goofy’ after standing
• Short of breath/unable to get deep breath
Gastrointestinal
•
•
•
•
•
•
•
Heartburn or reflux
Sick to the stomach (nausea) or vomiting.
Feeling bloated after a meal
Cramping or colicky abdominal pain
Diarrhea
Constipation
Excessive wind or gas (flatus)
None
None
None
None
None
Minimal
Minimal
Minimal
Minimal
Minimal
(6)
Mild
Mild
Mild
Mild
Mild
Moderate
Moderate
Moderate
Moderate
Moderate
Severe
Severe
Severe
Severe
Severe
Male Hormonal Issues (male only)
Extreme
Extreme
Extreme
Extreme
Extreme
Please answer each of following by checking the appropriate box.
Yes
No
2. Do you have a lack of energy?
3. Do you have a decrease in strength and/or endurance?
4. Do you have lost height?
5. Have you noticed a decreased "enjoyment of life"?
6. Are you sad and/or grumpy?
7. Are your erections less strong?
8. Have you noticed a recent deterioration in your ability to play sports?
9. Are you falling asleep after dinner?
10. Has there been a recent deterioration in your performance at work?
1. Do you have a decrease in libido (sex drive)?
Score_______
i.vii.3x
Please indicate if you have/have had any of the following:
Erectile dysfunction
Impotence
Breast pain/tenderness
Difficulty with urination
Prostatitis
Enlarged breasts (gynecomastia)
Infertility
Elevated PSA
Breast cancer
Venereal disease
Blood in urine (hematuria)
Testicle pain (testalgia)
Prostate cancer
Testicular cancer
Family hx of prostate cancer
Have you ever or are you currently using testosterone or DHEA supplements?
No
Yes, past
Yes, currently
(15)
Family History
Relationship
Father:
Age
Living / Deceased Diagnosis / Problems
Mother:
Siblings:
Children:
Do you have a family history of any of the following diseases? If so, please specify which relative:
Fatigue
Are you bothered by chronic fatigue?
Yes No
If yes, approximately when did you first begin to experience fatigue? Month/Year
How bad would you say your fatigue is on average?
Minimal
Mild
Moderate
Severe
Extreme
Is your fatigue constant or does it wax and wane?
Constant
Intermittent
Which statement(s) best describe your daily energy patterns?
My best energy of the day is usually in the (check one):
morning afternoon evening
My worst energy of the day is typically in the (check one): morning afternoon evening
Check all that apply:
I often get a burst of energy after a light meal or snack
I often get my ‘second wind’ fairly late at night.
I am exhausted after exertion and find it very hard to recover.
I am always tired and never have any energy.
What sorts of things make your fatigue worse?
Fibromyalgia:_______________________________________________________________________________
Other Chronic Pain condition (specify): __________________________________________________________
Chronic Fatique Syndrome: ___________________________________________________________________
What sorts of things make your fatigue better?
Attention Deficit-Hyperactivity Disorder (ADD/ADHD):________________________________________________
Parkinson’s Disease: _________________________________________________________________________
Multiple Sclerosis: ___________________________________________________________________________
Has your weight been stable over the last 6 months?
Alcohol Abuse/Dependence: ___________________________________________________________________
Drug Addiction: _____________________________________________________________________________
List your five most troublesome symptoms, from worst to least:
Depression: ________________________________________________________________________________
Bipolar Disorder (‘manic-depression’): ____________________________________________________________
Schizophrenia: ______________________________________________________________________________
Other mental illness (specify): __________________________________________________________________
Yes
No-gained______ lbs.
No-lost _______ lbs.
1.
2.
Notes – for office use only
3.
4.
5.
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(5)
Sleep
Developmental History
____________________
How long does it usually take you to fall asleep without medication?
____
What time do you typically go to bed?
AM
PM
____
What time do you typically wake up?
AM
PM
____ hours/night
About how many hours per night do you usually sleep?
How many times do you typically wake up to urinate? (circle)
0-1
2-3 4-5
6+
How many times do you wake up other than to urinate? (circle)
0-1
2-3 4-5
6+
Sleep-related symptoms
Yes
No
Do you dream or have nightmares?
Do you usually remember your dreams?
Do you get restorative/refreshing sleep?
Do your legs feel "restless or jittery" in the evening?
Does your bed partner say you kick your legs while asleep?
Do you grind your teeth at night?
Have you ever had a problem with sleep walking or unusual night-time activity?
Does your bed partner say you snore a lot?
Do you have acid reflux at night?
Do you sometimes stop breathing when you snore?
Do you ever awaken gagging or fighting for air?
Do you usually awaken with a headache?
Can you easily fall asleep in the afternoon?
Have you ever had a sleep study?
Please indicate if during your birth or childhood you had any of the following problems:
Maternal illness during pregnancy
Problem with delivery/obstetrical complications
Premature delivery
NICU stay
Bed-wetting after age 5
Learning disability
Dyslexia
Attention deficit disorder (ADD/ADHD)
Growing pains
Chronic abdominal pain or constipation
Frequent ear/nose/throat infections
Asthma
Please indicate if during your childhood/adolescence you experienced any of the following:
Death of parent(s)
Divorce of parents
Single parent
Adoption
Foster parenting
Frequent moves
Distant/cold parenting style
Alcoholic parent
Abuse: neglect
Abuse: physical*
Abuse: emotional*
Abuse: sexual*
If any items checked: have you received counseling or therapy for these issues?
Yes No
If yes, please describe:
• If yes, were you diagnosed with sleep apnea?
• When was the date of you last sleep study? (mm/dd/yy)
/
/
When did you last get a good night’s sleep? _____ (years) or ______(months) or _____ (days)
* We understand that issues of child abuse may be highly sensitive; however, being aware of any history of abuse
may play an important role in understanding symptoms and the best means by which to address them.
Social History
Marital Status:
Single
Married
Divorced
Occupation:
Work Status:
Full Part-Time Unemployed
ti
Other (describe):
Habits:
Past Current Describe:
Never
Slight
Moderate
High
Sitting, inactive in a public place (e.g. theater, meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Do you participate in any form of regular exercise? Yes No
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
Activity:
Watching TV
• If yes, please describe:
Score_______
(4)
Disabled
Retired
Effect on Symptoms
Worse
No Effect
Better
Alcohol
Tobacco
Caffeine
Marijuana
Cocaine
Amphetamines
Hallucinogens
Complete the following by indicating your chance of dozing off to sleep during the listed activities.
Widowed No. of Marriages: _____
(17)
Goals and Objectives:
What are your main goals/objectives for seeking help with this problem? What do you hope to
get from a treatment program?
1.
2.
What sorts of things make your pain worse?
Emotional distress
Worrying
Family Conflicts
Personal conflicts
Chemical exposures
Medication side effects
Physical injuries
Problems with sleep
Cold
Heat
Weather changes
Extending my neck
Physical inactivity
Light to moderate activity
Car travel
Airplane travel
Other (describe):
Mental stress
Perfectionism
Allergies
Infections
Humidity
Sitting still too long
Strenuous activity/exercise
Time zone changes
3.
In what ways do you foresee your life will change once you have met these goals?
Signature
Date
(18)
What sorts of things make your pain better?
Quality time with family/friends
Volunteer work
Resting/Relaxation
Distraction (e.g. reading, watching TV etc.)
Non-aerobic exercise (e.g. Yoga, Tai Chi)
Stretching
Running or jogging
Hypnosis
Massage/reflexology
Aromatherapy
Prescription pain medications
Prescription sleep medications
Prescription antidepressants
Pool therapy
Heat modalities (e.g. warm water, hot packs)
Chiropractic manipulation
TENS unit
Other (describe):
(3)
Social activities (e.g. clubs, church)
Counseling (e.g. psychologist, pastor)
Prayer/meditation
Getting enough sleep
Aerobic exercise (e.g. Pilates, Tai-Bo)
Walking
Strength training
Acupuncture
Biofeedback
Energy healing (e.g. Reiki)
Over-the-counter pain medications
Over-the-counter sleep medications
Nutritional supplements
Physical therapy
Cold therapy (e.g. ice packs)
Trigger point injections
Cranial Electrical Stimulation (e.g. Alpha-Stim)
FOR OFFICE USE ONLY
Pain
How severe is your pain most of the time?
None
Minimal
Mild
How would you describe your usual pain?
Flu-like ache, primarily in the muscles
Deep ache, bone pain
Cramping or tightness
Other (describe):
PHYSICIAN NOTES
Moderate
Severe
Extreme
Tenderness to palpation
Severe sensitivity to light touch
Burning sensations
How often do you get painful flare-ups?
Rarely
Infrequently
Frequently
How severe are your pain flares usually?
Please answer the following either yes or no
Mild
Moderate
Severe
Yes No
Do you have pain when you sitting still or not doing anything?
If yes, does the pain go away when you move around?
Does your pain get worse especially at night?
Does your pain get especially bad after exerting yourself, e.g. walking, gardening?
Does your pain get worse when you tilt your head back or extend your neck?
Please shade in the areas of your usual pain on the diagram below and indicate the 3
most painful areas (i.e. #1. #2, #3).
(2)
Patrick B. Wood, M.D.
FOR OFFICE USE ONLY
161 River Oaks Drive y Canton, MS 39046
Phone: (601)855-4810 y Fax: (601) 855-4313
PHYSICIAN NOTES
MROMC1331
8742720
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