Neuropathy Paperwork

Please fill out the application entirely and legibly. We need all information for insurance purposes.
Name
Nickname
Address
City
State
Zip
Phone *We will need to contact you both by phone & email. Please be sure to give us the best phone number to reach you
Format: (000) 000-0000.
Email
example@example.com
*If you have Medicare, we need you to list your SSN above or, provide US with the Medicare card*
Date of Birth

MonthDayYear
Date
Social Security
Spouse's Name
Phone Number
Format: (000) 000-0000.
Your Occupation
YesNo
Foot PainDiabetesSpinal StenosisCancerPinched NerveHand PainHigh CholesterolDegenerative DiscChemotherapyPoor CirculationLow Back PainHigh Blood PressureVascular ProblemsJoint ReplacementNeck PainPacemaker/ DefibrillatorFoot SurgeryFoot NumbnessHerniated DiscPlantar FascilitisImplanted Cord/ Bladder StimulatorPoor wound healingHand NumbnessBulging DiscMorton's NeuromaSciaticaExcessive thirst or urinationArthritis in HandsLeg PainArthritis in Feet
PRESENT HEALTH CONDITION
In order of importance, list the health problems you are most interested in getting corrected:
1.*
2.
3.
4.
List approximately how long you have noticed these problems:
1
2
3
4
Is there a certain time of day any of these problems are better or worse?
GabapentinNeurontinLyricaCymbaltaPhysical TherapyPain MedicationsAleveTylenolIbuprofenMotrinChiropracticMassage TherapyInjectionsCreams
Is your balance/walking ability affected? If yes, please describe
What do you think is causing your problem?
Name of all doctors you have seen for these problems and treatment you received:
ImprovedWorsenedStayed the same
List anything that makes your condition worse
List anything that makes your condition better
Aching PainNumbnessHot SensationCrampingStabbing PainTinglingThrobbing PainSwellingSharp PainPins & Needles PainDead FeelingBurningTirednessHeavy FeelingCold Hands/FeetElectric Shocks
SleepWorkDaily ActivitiesRecreational ActivitiesWalkingStanding
YesNo
If yes, how many cigarettes daily?
YesNo
If yes, how many drinks per week?
YesNo
If yes, please describe type & how often
CURRENT PAIN LEVELS?
How would you describe your pain last week?
If you had to accept some level of pain after completion of treatment, what would be an acceptable level?
This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization, unless you sign here indicating that we can release copies by your verbal request.
Name
Signature

Clear
Please give name, address, and office phone number of your primary care physician.
Name
Phone
Format: (000) 000-0000.
Address
When were you last seen there?
YesNo
List ALL allergies/sensitivities to medication, food, and other items here:
Item you react to
Reaction:
List the prescription drugs you are currently taking (or you may attach a list):
Name, Dose (mg or IU), Times Daily
List all nutritional supplements (vitamins, herbs, homeopathics, etc.) as above
You can choose to add a picture of your ID and insurance card to this form of bring it with you to your appointment.
Picture ID Front(Example Drivers license)

Cancelof
Picture ID Back

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Insurance Card 1 Front

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Insurance Card 1 Back

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Insurance Card 2 Front

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Insurance Card 2 Back

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Patient Quality Of Life Survey
Please take several minutes to answer these questions so we can help you get better. (Please circle as many that apply)
MedicationsEmergency RoomRoutine medicalExerciseNutrition/DietHolistic CareVitaminsChiropracticOther
Bad resultsSome resultsGreat resultsNothing changedDid not get worseDidn't work very longStill tryingConfused
3 a. No one is affected

b. Haven't noticed any problem c. They tell me to do something d. People avoid me
No one is affectedHaven't noticed any problemsThey tell me to do somethingPeople avoid me
4
JobKidsFuture abilityMarriageSelf-esteemSleepTimeFinancesFreedom
Family health problemsHeart diseaseCancerDiabetesArthritisFibromyalgiaDepressionChronic FatigueNeed surgery
How has your health condition affected your job, relationships, finances, family, or other activities? Please give examples
What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) Give 3 examples
What are you most concerned with regarding your problem?*
Where do you picture yourself being in the next 1 3 years if this problem is not taken care of? Please be specific
What would be different/better without this problem? Please be specific
> What do you desire most to get from working with us?
What would that mean to you?
Should be Empty: