Workmans_Compensation - MPMC Health History and Pain...

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MPMC Health History and Pain Questionnaire (Please use black ink) Thank you for completing the following questionnaire. The questions asked and your thorough response is critically important in developing a treatment plan specifically for you. Form completed by: ____________________________________________ Name: _________________________________________________________Date:________________ Address: ____________________________________________________________________________ City: ________________________________________ State: _____________ Zip: ________________ Phone (Home): (_____) ________________________ Work: (_____) ___________________________ Cell Phone: ________________________________ Email: _________________________________ Primary Care Physician: ____________________ Referring Physician: _________________________ Address: _________________________________ Address: __________________________________ Phone: __________________________________ Phone: ___________________________________ Current age: _____ Height: _____ Weight: _____ Weight one year ago: _____ Birthdate: __________ Marital Status: ( ) Married ( ) Single ( ) Divorced ( ) Widowed ( ) Domestic Partner How would you describe yourself: Aleutian Asian Black/African Middle Eastern White/Caucasian Hispanic/Latino Other (specify): ________________________________________________________ Hand Dominance: ( ) Right-handed ( ) Left-handed ( ) Ambidextrous What is your present or most recent occupation: _____________________________________________ Current Employment/Date last worked: _________________________ ( ) Full time ( ) Part time ( ) Retired ( ) Homemaker ( ) Unemployed due to pain ( ) Unemployed for other reasons (Specify) __________________________________________ With whom do you live: ___________________________ Relationship: ___________________________ Do they work outside of the home Y/N If so, employer/occupation: ____________________________ What is the highest grade you completed: ( ) Less than High School ( ) High School ( ) College ( ) Graduate School ( ) Other ____________________________________________________________________ 1
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What are your present sources of financial support: (Check all that apply) ( ) Salary/Employment Income ( ) Savings ( ) Disability ( ) Workers Compensation ( ) Insurance ( ) Other: ________________________________ Workman’s Compensation patients please complete the following questions 1. Who is your Primary Treating Physician: ____________________________________________ 2. Are you represented by an attorney: Y/N Name: ____________________________________ Address: ________________________________________ Phone: ______________________ 3. Status: Please indicate the date of determination for the following: _________________ ( ) Temporary Total Disabled ( ) Permanent and Stationary ( ) Disability Rating ______________ ( ) Medically Rated __________________ If you have settled your claim, do you have future medical care: Yes/No Pain History: 1. What is the problem for which you were referred (Chief complaint):_____________________. 2.
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This note was uploaded on 10/27/2011 for the course PHYCOLOGY 101 taught by Professor Eins'tein during the Spring '11 term at Albany Medical College.

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Workmans_Compensation - MPMC Health History and Pain...

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