• Patient Follow-Up Form

  • Please answer the following questions:

  • Onset of pain?*
  • What is the main reason for your visit today?*
  • Are you or could you be pregnant?*
  • Are you a smoker?*
  • Select one number that describes your average pain score since your last visit:*
  • What number best describes how, in the past week, the pain interfered with your enjoyment of life:*

  • Please answer the following questions:

  • Since the last visit, describe the amount of relief you have from the injections/medications provided:*
  • How much improvement do you have in your functional ability to do things you want/need to do?*

  • Please answer the following questions:

    0 represents no pain, 10 represents severe pain
  • What is your pain like today?*
  • What is your least pain?*
  • What is your worst pain?*
  • Overall average pain?*

  • Please answer the following questions:

  • Which words best describe your pain? (Select all that apply)*
  • Which words best describe the timing of the pain? (Select all that apply)*
  • Which of the following symptoms is the pain associated with? (Select all that apply)*
  • Which of the following make the pain worse? (Select all that apply)*
  • Which factors seem to relieve the pain? (Select all that apply)*

  • Are you experiencing any of the following?

  • General:
  • Cardiac:
  • Hematological:
  • Eye:
  • Genitourina:
  • Neurologic:
  • Psychiatric:
  • Respiratory:
  • Skin:
  • ENT:
  • Gastrointestinal:

  • Please answer the following questions:

  • Could you please complete this questionnaire? It is designed to give us information as to how your pain has affected your ability to manage in every day life.

     

    Please answer every section. Mark one box only in each section that most closely describes yout today.

  • Pain Intensity*
  • Personal care (washing, dressing, etc.)*
  • Lifting*
  • Walking*
  • Sitting*
  • Standing*
  • Sleeping*
  • Sex life*
  • Social life*
  • Traveling*
  • Should be Empty: