Appointment:
Address:
Complete Address
Phone
2 Current Dentist / Doctors
List the names and COMPLETE addresses of all health care practitioners you are currently seeing
NAME SPECIALTY
ADDRESS PHONE
NAME SPECIALTY
ADDRESS PHONE
It is the policy to forward copies of our medical report to you medical GP, Dentist and any other
specialists unless we are advised otherwise.
3. Understanding Your Complaint
A. Describe thoroughly in your own words the problem you would like help with:
B. How often does your pain occur? C. What is the duration of your pain? (Length it lasts)
Continuous None
Several times a day Seconds
Once per day Minutes
Once per week Hours
Less than once per week Days
Never Weeks
Continuous
F. Circle a number below to indicate your lowest pain intensity over the past week
0 1 2 3 4 5 6 7 8 9 10
No pain Mild pain Moderate pain Severe pain
0 1 2 3 4 5 6 7 8 9 10
No pain Mild pain Moderate pain Severe pain
H. Below is a list of words that may describe your pain. Please tick the word(s) that most closelyMost
describe your
intense pain
pain. imaginable
Throbbing Shooting Stabbing Sharp
Cramping Cramping Gnawing Hot Burning
Aching Heavy Tender Splitting
Tiring- Exhausting Sickening Fearful Punishing-Cruel
Left
Right
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4. Effects of Pain
A. Circle the number to indicate how much your pain has interfered with your activities this past week
0 1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe
No Interference
B. Circle the number to indicate how distressed or bothered you have been in the past week about Complete
the pain Interference
0 1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe
None
The most
5. Current Medications
severe
List ALL medicines you are currently taking for medical and pain problems (including prescribed, over the
imaginable
counter, herbs, vitamins): (Write on the back of this sheet if necessary).
Name Pill Strength Number of times taken per day Doctor who prescribed
© Éamonn MurphyPS#1 CLERMONT CLINIC, DOUGLAS ROAD, CORK. TEL: (021) 4294590
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7. Previous Doctors
List all doctors you have seen for your pain problem (continue on the back of the sheet if needed)
Date Name Specialty Address / Phone
9. Previous Treatments
Indicate which of the following treatments you have tried for your pain problem:
12. Allergies
List all allergies to medications and the reaction you had to any medicine:
Medicine Reaction Medicine Reaction
© Éamonn MurphyPS#1 CLERMONT CLINIC, DOUGLAS ROAD, CORK. TEL: (021) 4294590
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J. Infections
F. Gastrointestinal measles
Abdominal pain mumps
Nausea or vomiting chicken pox
Constipation or diarrhea rheumatic fever
History of ulcers or heartburn hepatitis
HIV / AIDS
G. Genitourinary
14. Past Medical Problems: Please indicate any other medical problems you have had.
2. Mother
3. Brothers / Sisters
4. Children
© Éamonn MurphyPS#1 CLERMONT CLINIC, DOUGLAS ROAD, CORK. TEL: (021) 4294590
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B. Employment Status:
Employed F/T Retired Are you on disability? Y / N
Employed P/T Unemployed due to pain Date disability started:
Self employed Unemployed due to other Reason for disability:
Homemaker reasons:
How long have you been
unemployed or retired?
C. Number of hours worked per week: Are you happy with your job?
Your current or most recent occupation
IMPORTANT NOTE:
It is the policy of this practice to request payment of fees for treatment provided, at the end of every visit. Any other
arrangements with regard to payment of account due, should be agreed prior to commencement of treatment.
I have read the above notice regarding the payment of treatment of fees and I undertake to abide by the conditions quoted
above.
Signed:
© Éamonn MurphyPS#1 CLERMONT CLINIC, DOUGLAS ROAD, CORK. TEL: (021) 4294590