Advanced Pain Management Consultants

Do you have pain?            We want to help you manage your pain.            At Advanced Pain Management Consultants

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Dr. Chowdhury

Gina Pastore A.R.N.P.

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Dr. S. Chowdhury M.D. and Gina Pastore, A.R.N.P..

 

ASSESS YOUR PAIN

   Comfort Assessment Daily Journal

This page is designed to help you assess your pain. 

The most important thing you can do is tell your physician about your pain.  Often, patients assume their Doctor can tell that they are having pain, but this is not always the case.  Only you know when you're in pain, how bad it is and what it feels like.

Dr. Chowdhury and Gina Pastore A.R.N.P. not only needs to know about your pain, he wants to know.   Sometimes you may feel intimidated or like the Doctor has more important things to do.  Dr. Chowdhury believes that you deserve and are entitled to proper pain management and the very best care available according to your particular needs.

How To Prepare For Your Appointment

When describing your pain and symptoms, always BE:

    Prepared         *Using the below resources, notes, questions, etc.

     Accurate         *In describing your pain and symptoms.

    Inquiring         *Don't be afraid to ask questions.

  kNowledgable  *Educate yourself about your disease or particular condition and any options that are available.

Advanced Pain Management Consultants Susanti K. Chowdhury, M.D., P.A. and Gina Pastore, M.S.N., A.R.N.P.  Pain Questionnaire

[FrontPage Save Results Component]

Your name:	_______________________________________
Date of birth and age:	________________      ____________
Referring doctor/source: telephone number:	_______________________________________
When/how did your pain begin? (Work related, accident, spontaneous, etc.)
Describe the area of where your pain exists.
Please shade in affected areas associated with the pain.
What is your pain score? 0= no pain 10= most severe pain possible	Pain score today ______/10 Pain score on my best day? ______/10 Pain score on my worst day?  ______/10
Describe your pain.  (check all that apply)	burning   throbbing  sharp   dull   shooting aching   squeezing
Describe your pain pattern.	constant   75% of the time  50%  25%
Associate symptoms: (check all that apply)	numbness    weakness    warmth    coldness  tingling    sweating   swelling    spasms    changes in skin color     loss of bowel/bladder control
Aggravating events:  (check all that apply)	standing   sitting  lying down  walking sexual activity  eating  heat  cold coughing  sneezing  work related motions stress   Other:__________________________
What has helped your pain in the past?
List physicians who have treated you for your pain condition & approximate dates.
Have you been previously evaluated by a Pain Specialist?   (name and date)
Please list your primary care physician and date late seen. Date of last physical exam?
Treatments you have received: (check all that apply)	Nerve blocks / Injections  Physical therapy  Tens   Exercise  Psychological treatment  Surgery  Biofeedback  Acupuncture  Chiropractic    Cane/Walker  Brace/support   Massage  Relaxation     Epidural injection    Facet injection    Spinal stimulator    Morphine pump Other:____________________________________
Please list all medications which you have previously taken and any that you are currently taking for your pain.	CURRENTLY TAKING PREVIOUSLY TAKEN
Previous testing:  * (please check any that apply)     *Please bring films/reports to your appointment.	X-Ray   MRI   CT Scan   Myelogram        EMG(nerve conduction)   Thermography       Bone Scan   Discogram    List dates and facility:
Past medical history: (check all that apply)	coronary artery disease  heart attack    heart failure    valve problems   hypertension     emphysema    asthma  hepatitis   ulcers   heartburn   strokes/TIA  hiatal hernia   kidney disorder   cancer (include skin)     history of liver disorder   diabetes    HIV    thyroid disease   epilepsy   seizures   paralysis   blindness Other: ___________________________________
Past surgical history:   (check all that apply)	gallbladder    hernia   cataract                appendectomy    low back surgery   neck surgery    hip    knee Other:___________________________________
Current medications: (list name and dose
Medication allergies:
Marital Status:	Married    #of years________    Single            Divorced   Widowed    Other ______________
List people whom you live with; relationship; and their health:
Have you ever smoked?	yes     no     How much do you smoke?____                                           If you have quit, when?_______________
Do you drink alcohol?	Never   Socially   Weekly   Daily
Have you ever used recreational or street drugs?	yes    no
Have you ever been treated for drug or alcohol abuse?	yes    no
Please list trades or jobs which you have worked in the past.
Date of last employment? (If current, list hours/week)	________________________________
Have you spoken to an attorney with regards to your pain?	yes    no Is your case pending or completed?
Have any of your blood relatives had any of the following:   (check all that apply)	coronary artery disease    hypertension         seizures    diabetes   psychiatric history    bleeding disorders   cancer   stroke

 

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Please print this form (landscape orientation) and bring to you initial appointment

*** When You arrive for your appointment, be sure to bring proper identification, insurance card(s) and reports (medical records, MRIs, X-rays, or other relevant paperwork).  We will have you sign the form you just completed for confirmation and Release of Information to Insurance Companies.***

Please Call us for an appointment at 727-526-2771.  Be sure to also fill out the patient information form and bring to your initial appointment.  

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