• Patient Summary

    In order to schedule an appointment with Dr. Williams, he requests that each patient complete this form. Please answer the questions below and provide a detailed patient summary of your condition from the very start of the problem up to the present time. The summary should be as detailed as possible yet limited to just the information that is relevant to the specific problem you are coming to Dr. Williams for. The summary should be written down in chronological order as you have experienced them. Avoid dramatic or emotional embellishment of your story. Above all, be sure to give a detailed, accurate description of where in your body your pain and other symptoms are located throughout your story. Peripheral nerves go to specific places. If you are inaccurate with your descriptions of where your pain is located, it could result in the wrong nerve(s) being identified which delays correct diagnosis and treatment. All records will be required before scheduling an appointment and must be uploaded to this form.
  • Date of birth?*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Phone Number - Please select country code from the drop-down next to the flag*
  • How did you hear about us?*
  • Biological sex*
  • Height and weight*
  • What SIDE of your body is the pain located?*
  • What area is your primary concern?*
  • What TYPE of pain are you experiencing?*

  • Is the pain in your thigh ONLY on the outer part of your thigh?*
  • Have you been diagnosed with Meralgia Paresthetica?*
  • Have you had a nerve block of the Lateral Femoral Cutaneous Nerve (LFCN)?*
  • Were you numb/pain free for a few hours directly after the block?*
  • Have you been told by a doctor that you do not have any issues with your spine?*

  • *If you have not already done so, you will need to have an MRI of your Lumbar Spine (lower back) BEFORE scheduling an appointment to rule out a spine issue*

  • Have you been told by a doctor that you do not have any issues with your hip?*
  • Have you been told / suspect you have Occipital Neuralgia?

  • *If you have not already done so, you will need to have two separate successful occipital nerve blocks BEFORE scheduling an appointment*

    This can be done by a pain management team. If the pain did not go away for 4-8 hours giving you blissful relief AND the back of your head did not go numb, the nerve block was not successful.

  • Do you have a Foot Drop?*

  • ******** FOOT DROP ********

  • **Please note- forms WILL NOT be reviewed if you do not complete the next question**

    This is an extremely important piece of information Dr. Williams requires
  • Use the camera icon below to take/upload a photo and you can then draw and annotate on the photo below. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
  • Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
  • Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
  • Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
  • Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
  • Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
  • Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
  • Did your pain start after a trauma (i.e. fall, accident, injury) or surgery*

  • ***For all questions below, please be SPECIFIC and detailed in your responses***

  • If Dr. Williams deems surgery necessary, how soon are you hoping to schedule a surgery with him?*

  • History of treatment

    Please note, no appointments will be scheduled until we have received all records required.
  • Please select the following that you have tried ONLY as it relates to the pain you would like to be seen for.*

  • If you have not had an MRI or EMG done within 6 months before your appointment, please have both of these done and have the reports sent to us BEFORE your appointment with Dr. Williams to avoid delaying diagnosis and treatment.

  • If you have not had an MRI done within 6 months before your appointment, please have a new one done and have the reports sent to us BEFORE your appointment with Dr. Williams to avoid delaying diagnosis and treatment.

  • We cannot accept screenshots, or photos of records, we need clear PDF documents for each record. You can save this form and come back to it later if needed.

  • Reports are required to schedule an appointment. Please choose one of the following:*
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  • Reports are required to schedule an appointment. Please choose one of the following:*
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  • Did any of the injection(s) help - even for a short period of time?*

  • For most diagnoses, Dr. Williams prefers two successful nerve blocks to be done to 'stack the evidence' to confirm your diagnosis. While you are waiting for your appointment, if you have not already done so, we recommend that you try to have these done BEFORE seeing Dr. Williams and having the notes sent to us. This will make your appointment with Dr. Williams much more effective and efficient.

     

    What is a successful nerve block?

    The pain that you want to see Dr. Williams for is gone temporarily (usually 4-8 hours). 

     

  • Reports are required to schedule an appointment. Please choose one of the following:*
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  • Reports are required to schedule an appointment. Please choose one of the following:*
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  • **An appointment will not be scheduled until your faxed records have been received**

    Our fax number is 410-337-5520
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