Functional Health Assessment | SSMC secure patient forms

1Patient Identification

Patient name (legal, as on ID):

Last

First

Middle

Preferred name:

Date of birth (DD/MM/YYYY):

//

Age:

Sex:

MaleFemaleOther / Prefer not to say

National ID / Passport #:

Primary language

KhmerEnglish

Other:

Translator needed?

YesNo

2Contact

Mobile phone:

Email:

Address (street, district, province):

Emergency contact (name / relation / phone):

3Referral & Care Team

Primary care physician (name / clinic / phone):

Who referred you to SSMC Pain & Wellness? (name / clinic):

Reason for your visit:

4Pain Location

On the body diagram below, mark an “X” on each place where you are experiencing pain for which you were referred to SSMC Pain & Wellness.

Tap the drawing to place an X; tap an X again to remove it.

5Primary Pain Region (ODI / NDI routing)

Check the ONE area that is your main pain problem (you can mark other areas on the body diagram above).

6Pain Severity

On the scale below, check the box of the number that most closely indicates the level of your pain.

How many times per day does this pain occur?

When did your pain start:

//day optional

How did your pain start?

SuddenlyGraduallyOn and off

7Diagnostic Tests

Have you had any of the following diagnostic tests for this pain?

8Treatments Tried for This Pain

9Current Medications for Pain

List all medications, supplements, and herbal products you are currently taking for this pain problem.

Medication / Drug Name	Dose / Route	Time / Frequency	Reason

Are you currently taking, or have you recently taken, opioid pain medicine (ORT routing) (for example tramadol, codeine, morphine, oxycodone, fentanyl patches)?

No

Yes — which:

10Allergies, Sensitivities & Medication Reactions

I have no known allergies, sensitivities, or medication reactions.

Allergy / Sensitivity

Medication:

Type of Reaction

Contrast / X-ray dye:

Type of Reaction

Local anesthetic (numbing injection, e.g. at the dentist)

Type of Reaction

Skin cleanser or tape (chlorhexidine, iodine / Betadine, adhesive)

Type of Reaction

Latex:

Type of Reaction

Other:

Type of Reaction

11Blood Thinners & Medicines That Affect Bleeding (critical for procedure safety)

Are you taking any of the following? Check all that apply. Do not stop any medicine on your own — the doctor will tell you if and when to stop it before a procedure.

If you take a blood thinner — prescribing doctor (name / clinic):

Doctor’s phone:

Reason:

Anti-inflammatory painkillers (ibuprofen, naproxen, diclofenac, meloxicam…):

NoYes

If yes — which one(s), and how often:

Supplements — these are stopped 6 days before some spine injections (the doctor will tell you if this applies to you)

Fish oil / omega-3Vitamin EGarlic supplementNone of these

12Pain Interference

Has your pain interfered with any of the following?

13Substance Use

14Work, Family & Social

Occupation:

How physical is your work?

SedentaryLightMediumHeavy

Marital status:

SingleDivorcedMarriedWidow / Widower

Children:

No

Yes — # of children:

Who lives with you?:

15Mood, Anxiety & Trauma Screen (PHQ-9 / GAD-7 / PTSD routing)

Over the last 2 weeks, how often have you been bothered by any of the following problems? Check one box per line.

Trauma screen

Some people have lived through a very frightening, terrible, or upsetting event (for example an accident, serious illness, violence, or wartime experience). These questions are confidential.

Have you ever experienced an event like this?

NoYes

If yes — in the past month, have you had nightmares about it, or thought about it when you did not want to?

NoYes

If yes — in the past month, have you tried hard not to think about it, or gone out of your way to avoid reminders?

NoYes

16Coping & Stress

Has pain made it more difficult to cope with stress?

NoYes

Please describe how you handle stress in your life:

Do you practice any religion or have a personal faith system which helps you cope better with the pain?

17Safety & Wellbeing

These questions are asked of all patients. Your answers are confidential and will be discussed only with your physician. If you would like to speak privately with a member of our staff, please tell the nurse or physician at any point during your visit.

Have you ever felt unsafe at home?

NoYes

Have you ever been emotionally, physically, or sexually hurt by your partner or someone close to you?

NoYes

Is there anything happening in your family or home life which is upsetting you?

NoYes

18Patient Certification

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status.

Who is completing this form?

Patient’s SignaturePerson authorized to sign for patient

Type your full name as your signature *

Relationship to patient

I confirm the statement above. Typing my name here is my signature. *