Pain And Nutrition Subjective Data
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| Questions | Findings |
| Current Status | |
| 1. Allergies | |
| 2. Present health concerns | |
| 3. Current medications (prescribed and over-the-counter) | |
| 4. Immunizations | |
| Past History | |
| 5. Medical | |
| 6. Surgical | |
| 7. Hospitalizations | |
| 8. Injuries | |
| Family History | |
| 9. List family medical concerns for 3 generations | |
| Pain | (Everyone has had pain at some time or other-if your patient is healthy and currently pain-free, you may need to use a past instance of pain.) |
| 10. Pain (using COLDSPA)
Character: how does it feel—what sort of pain is it? |
|
| 11. Onset: | |
| 12. Location: | |
| 13. Duration: | |
| 14. Severity (scale of 1 – 10): | |
| 15. Pattern—what makes it better or worse: | |
| 16. Associated factors—does it cause you to have other symptoms too? | |
| 18. How does pain impact the other areas of life? | 2. What are your concerns about the pain’s effect on
a. general activity? b. mood/emotions? c. concentration? d. physical ability? e. work? f. relations with other people? g. sleep? h. appetite? i. enjoyment of life? |
| Lifestyle and Health Practices | |
| What types of recreation or physical exercise? | |
| Duration of exercise periods, how many times per week? | |
| Stress: Rate overall life stress on a scale of 1 – 10 (1 being least, 10 most). What are the greatest sources of stress? | |
| Methods of coping with stress? | |
| Use of tobacco, alcohol, recreational drugs | |
| Sleep—typical hours per night |
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