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. (16) (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 (1)
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