Please complete and bring to your apt.

Appointment:

COMPLAINT EVALUATION FORM Date:

Name:
First Last

Address:

Tel. #: Date of Birth Gender: Male Female

Age: Dominant Hand: Right Left Height: Weight:

1. Referring Dentist or Doctor:

Complete Name of Referring Doctor:
Last First

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

D. When is your pain worse?

 Morning
 Mid day
E. Circle a number below to indicate your highest pain intensity over the past week
 Evening
 Nighttime
0 1 2 3 4 5 6 7 8 9 10
No pain Mild pain Moderate pain Severe pain

Most intense pain

imaginable
© Éamonn MurphyPS#1
 26505551.doc: Page 2 of 6

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

Most intense pain

G. Circle a number below to indicate your usual pain intensity over the past week imaginable

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

I. Please indicate clearly and comprehensively where you have pain:

Left
Right

© Éamonn MurphyPS#1 CLERMONT CLINIC, DOUGLAS ROAD, CORK. TEL: (021) 4294590
 26505551.doc: Page 3 of 6

J. What makes the pain WORSE? Be Specific.

K. What makes the pain BETTER? Be Specific.

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

6. History of Your Pain

A. When did your pain start?
B. When did your pain become a problem?
C. What event or events lead to your present pain:
accident other injury other disease other
cancer no obvious cause following an operation

D. What do YOU think is the cause of your pain?

E. Is your pain getting better or worse? Be specific.

© Éamonn MurphyPS#1 CLERMONT CLINIC, DOUGLAS ROAD, CORK. TEL: (021) 4294590
 26505551.doc: Page 4 of 6

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

8. X-rays and Tests

Please list in chronological order, all tests and x rays performed to evaluate your pain:
Date Test Result

9. Previous Treatments
Indicate which of the following treatments you have tried for your pain problem:

anti-inflammatory antidepressants acupuncture biofeedback

homeopathy chiropractor TENS narcotic painkillers
nerve blocks physiotherapy hypnosis relaxation training
exercise program traction psychotherapy other (list)

10. Previous Medications

List all previous pain medications you have taken for pain:
Name of medicine Dose Dates of use Helpful? Reason for stopping
YES / NO
YES / NO
YES / NO
YES / NO
11. Surgeries
List all previous hospitalisations, or injuries you have ever had:
Year Type of Surgery Hospital Doctor

12. Allergies
List all allergies to medications and the reaction you had to any medicine:
Medicine Reaction Medicine Reaction

13. Review of Systems

Please check if you have or had any of the following:
A. General nail changes
weight loss bumps/nodules
poor appetite herpes
severe fatigue / low energy
C. Head and Neck
B. Skin headaches
rash visual changes

© Éamonn MurphyPS#1 CLERMONT CLINIC, DOUGLAS ROAD, CORK. TEL: (021) 4294590
 26505551.doc: Page 5 of 6

mouth problems pregnant

thyroid problems frequent or hesitant urination
neck pain pain with urination
difficulty swallowing blood in urine
incontinence
D. Haematological sexual dysfunction
anemia
easy bruising H. Musculoskeletal
bleeding problems Arthritis Type:
taking blood thinners osteoporosis
muscle pain
E. Cardiopulmonary muscle wasting
Shortness of breath fractures
cough
exercise limitations Neurologic
chest pain numbness
irregular heartbeat weakness
heart murmurs falling or loss of balance
high or low blood pressure stroke
circulation problems seizures
ankle swelling memory loss

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.

15. Habit History

A. Smoking: Yes No Quit. Number per day Number of years smoked .
B. Alcohol Use: None Occasional Daily How much per week .
C. Recreational Drugs: Current Use? Yes No
D. Coffee / Tea / Caffeine: Number of cups per day
E. Clenching Teeth: Yes No
F. Grinding Teeth: Yes No
G. Do you wear an intra-oral splint (night guard)? Yes No
H. Do you chew gum? Yes No
I. Do you bite your nails? Yes No
J. Is anyone concerned about your use of alcohol, drugs, or medications? Yes No

16. Family History

Member Deceased or Living Age Medical Problems
1. Father

2. Mother
3. Brothers / Sisters
4. Children

© Éamonn MurphyPS#1 CLERMONT CLINIC, DOUGLAS ROAD, CORK. TEL: (021) 4294590
 26505551.doc: Page 6 of 6

Does anyone in your family suffer from TMJ / Facial Pain?

Is there a history of arthritis in your family?
Are you adopted? Yes No

17. Social History

A. Relationship Status:
Single Married Separated Widowed Divorced

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

18. Financial History

Do you have any legal action pending related to this pain or any other health problem? Yes No

19. Psychological History

1. Describe your mood.

Do you have problems with any of the following:

concentration anxiety appetite motivation
depression sleep self-worth suicidal thoughts

2. Are you currently seeing a doctor for mood problems? Yes No

3. If Yes, Name Phone

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