Michigan Interventional Pain Associates

West Bloomfield, MI

We Care ~ We Support ~ We Follow Up

Phone: 248-624-7246 | Fax: 248-624-2597 info@lakespm.com | Patient Portal

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- Procedures
- Spinal Cord Stimulation
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Referring Physicians
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New Patient Package Consult B

Please fill out the following questionnaire.

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Referring Physician
Referring physician name*
First Last
Referring physician address
Street Address City State ZIP Code
Referring physician phone
Primary Physician
Primary physician name
First Last
Primary physician address
Street Address City State ZIP Code
Primary physician phone

Indicate location of pain (check all that apply)
- Abdomen
- Arm Left
- Arm Right
- Buttock Left
- Buttock Right
- Chest
- Elbow Left
- Elbow Right
- Foot Left
- Foot Right
- Groin Left
- Groin Right
- Hand Left
- Hand Right
- Head
- Hip Left
- Hip Right
- Knee Left
- Knee Right
- Leg Left Lower
- Leg Right Lower
- Lower Back
- Mid Back
- Neck
- Shoulder Left
- Shoulder Right
- Thigh Left
- Thigh Right
- Upper Back
Other pain location (please describe)
History of Present Illness
Under what circumstances did your pain begin?
- accident at work
- accident at home
- work related
- pain just began
- motor vehicle accident
- following surgery
- following illness
- other
Please describe other circumstances
Place of employment
Date of injury
Type of work
What were you doing when the pain occurred
Currently, what is your pain score?
What is the highest your pain score that you have ever had?
What is the lowest pain score that you have ever had?
How long have you had this pain problem (yrs/months/days)
When did you first notice your pain?
Timing of your pain (when is it the worst)
- First thing in the morning
- Later in the morning
- Afternoon
- Evening
- Bedtime
- Pain is ALWAYS the same
Description of your pain
- Burning
- Sharp
- Aching
- Throbbing
- Shooting
- Stabbing
- Other
Please describe your pain
Associated signs and symptoms
- Numbness
- Tingling
- Pins and Needles
- Weakness
- Coldness
- Swelling
- Muscle Spasm
- Tightness
- Skin Discoloration
- Bowel or Bladder Problems
What activities increase your pain
- Sitting
- Standing
- Lying
- Worry/Stress
- Driving
- Walking
- Weather
- Time of Day
- Activities
- Sex
Which of the following decrease your pain
- Rest
- Lying
- Medications
- Sitting
- Standing
- Drug/Alcohol
- Physical Activity
- Time of Day

Please indicate which of the following you have tried if any
Acupuncture*
- Yes
- No
How long, was it helpful?*
Date of last treatment / use*
Biofeedback*
- Yes
- No
How long, was it helpful?*
Date of last treatment / use*
Chiropractor*
- Yes
- No
How long, was it helpful?*
Date of last treatment / use*
Heat*
- Yes
- No
How long, was it helpful*
Date of last treatment / use*
Hypnosis*
- Yes
- No
How long, was it helpful*
Date of last treatment / use*
Ice*
- Yes
- No
How long, was it helpful*
Date of last treatment / use*
Illicit (street drugs)*
- Yes
- No
How long, was it helpful*
Date of last treatment / use*
Massage*
- Yes
- No
How long, was it helpful*
Date of last treatment / use*
Prescribed pain medicine*
- Yes
- No
How long, was it helpful*
Date of last treatment / use*
Physical therapy*
- Yes
- No
Where did you go
How long, was it helpful*
Date of last treatment / use*
Nerve blocks*
- Yes
- No
How long, was it helpful*
Date and location of injections*
Therapy/counseling*
- Yes
- No
How long, was it helpful*
Date of last treatment / use*
Surgery*
- Yes
- No
How long, was it helpful*
Date of surgeries*
Steroid treatment*
- Yes
- No
How long, was it helpful*
Date and location of last treatment*
TENS*
- Yes
- No
How long, was it helpful*
Date of last treatment / use*
Procedure/injection*
- Yes
- No
How long, was it helpful
Date and location of all procedures/injections*
Do you currently use or have you ever used
- Walker
- Cane
- Wheelchair

Medical History
Have you had*
- Anemia
- Angina/Chest Pain
- Anxiety
- Aspirin/Anti- Inflammatory Use
- Asthma/Emphysema/Bronchitis
- Atrial Fibrillation
- Bladder Incontinence
- Bleeding/Bruising/Clotting Disorder
- Blood Thinner Use
- Bone/Muscle Pain
- Bowel Incontinence
- Cancer
- Chest Pain
- Congestive Heart Failure
- Constipation
- Depression
- Diabetes (Insulin Dependent)
- Diabetes (Non-Insulin Dependent)
- Ear/Nose/Throat Problems
- Eye/Vision Problems
- Fainting/Black Outs
- Fevers/Chills
- Gerd/Acid Reflux
- Heart Attack
- Heart Murmur/Rheumatic Fever
- Hepatitis
- Herpes/Other
- Hiatal Hernia
- HIV
- Hypertension (High Blood Pressure)
- Irregular Heart Beat
- Kidney Disease
- Liver Disease
- MVP Or Valvular Disease
- Osteoarthritis
- Paralysis
- Phlebitis
- Pneumonia
- Polio
- Problems Breathing
- Problems Breathing
- Problems With Anesthesia
- Prostate Problems
- Psychiatric Illness/Depression
- Recent Cold/Sore Throat/Cough
- Recent Exposure To A Communicable Disease
- Rheumatoid Arthritis
- Rheumatoid Arthritis
- Seizures/Epilepsy
- Shortness Of Breath
- Sickle Cell Disease
- Significant Weight Loss Or Weight Gain In The Last Year
- Skin Rash/Skin Conditions
- Sleep Apnea
- Snoring
- Stomach Pain
- Stroke
- TB
- Thyroid Disease/Goiter
- Urinary Incontinence
- None of the above
Type of cancer and treatment*
Have you had*
- Chronic Pain
- Diabetes
- Heart attack/High Blood Pressure
- Breast Cancer/Colon Cancer
- Psychiatric Illness/Depression
- Disability
- None of the above
Medical history comments
Females only
First day of your last menstrual period
Are your periods normal?
- Yes
- No
Any abnormal vaginal / breast discharge?
- Yes
- No
Number of pregnancies
Number of deliveries
Past Surgical History
Do you have any past surgical history?*
- Yes
- No
Please list all the operations you have undergone, including the year they were performed*
Year Operation
Medications
Do you take any non-pain medications*
- Yes
- No
Please list all the non-pain medications you are currently taking, including the dosage.*
Do you take any pain medications?*
- Yes
- No
Please list all the pain medications you are currently taking, including the dosage.*
What pain medications have you tried in the past for your pain? Please list all and explain why you no longer taking them.
Do you have any drug allergies, sensitivity or reaction?*
- Yes
- No
Describe Drug Allergies/Sensitivity - Reaction*
Environmental / Food Allergies: (iodine, dye, mold, dust, pollen, cats, dogs, eggs…)
Family Medical History
Do you have any Family Medical History?*
- Yes
- No
Has anyone in your family had*
- Asthma/emphysema
- Hypertension
- Heart Attacks/Angina
- Congestive Heart Failure
- MVP or Valvular Disease
- Cancer
- Diabetes
- Arthritis
- Depression
- Sleep Apnea
- Mental Illness
- Other
Who in family had medical history?*
- Mother
- Father
- Siblings
- Grandparents
Describe other family medical history

Personal Habits
Do you smoke?*
- Yes
- No
How much per day?*
Are you a previous smoker?*
Do you drink alcohol?*
- Yes
- No
How much alcohol do you drink?
Have you ever had a problem with drugs or alcohol?*
- Yes
- No
Do you have a history of illicit/street drug use?*
- Yes
- No
What drugs have you used?
How many caffeinated beverages do you consume daily
How often do you see a doctor?
- 3 or more times per month
- 1 – 2 times per month
- less than once a month
Social/Occupational History
Marital Status
Spouse’s name
First Last
Number of children?
Ages?
Who shares your home?
Occupation
How long at this position?
Brief description of job duties
Work Status
If disabled, date last worked
If working less than full time is pain the reason?
If you had no pain would you return to work?
Has your employer been helpful and understanding of your problem?
- Yes
- No
What would you hope to be the end result of this evaluation?
- Medical diagnosis
- Recommendations for surgery
- Recommendations for medications
- Recommendations for rehabilitation
If you are treated here, what are the results you HOPE for?
- Pain reduction
- Increased recreation
- Improved emotional well- being
- Increased socialization
- Return to work
If you are treated here, what are the results you EXPECT?
Upload your imaging reports
CT scan, X-Rays, MRI written reports
Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx.
Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx.
Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx.
Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx.
Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx.
Additional Information
Appointment Date
Appointment Time

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MM
Pharmacy Name, cross roads and City
Advance Directives
- DNR - Do Not Resuscitate
- GUARD - Guardianship
- LW - Living Will
- POA - Power of Attorney
- NE - Not Establish

Affiliations

Huron Valley-Sinai Hospital
St. John Providence Park Hospitals

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Office Hours

Monday	8.00am – 4.00pm
Tuesday	8.00am – 4.00pm
Wednesday	8.00am – 4.00pm
Thursday	8.00am – 4.00pm
Friday	8.00am – 2.00pm
Saturday	Closed
Sunday	Closed

Contact Information

Michigan Interventional Pain Associates
Phone: 248-624-7246
Fax: 248-624-2597

West Bloomfield
2300 Haggerty Rd. Suite 2100
West Bloomfield, MI 48323

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