Neuropathy Consult ROF

Neuropathy Consult ROF
Your Information
Which office are you visiting?*
First Name*
Middle Initial
Last Name*
Nickname*
Address*
City*
State*
Zip*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*
Social Security Number*
Spouse Name
Spouse Phone Nbr.
Occupation
Retired?

YesNoOther
Primary Doctor Information
Name:
Phone:
Address:
Most Recent Visit to Your Primary:
Date. An approximation is fine.
Can we send medically-necessary updates?

YesNo
Review of Symptoms
Please check all that apply*

Foot PainHerniated DiscArthritis (hands)Hand PainBulging DiscArthritis (feet)Low Back PainSpinal StenosisPlantar FasciitisNeck PainDegenerative DiscSciaticaFoot NumbnessVascular IssuesPinched NerveHand NumbnessLeg PainPoor CirculationDiabetesMorton's NeruomaJoint ReplacementHigh CholesterolCancerFoot SurgeryHigh Blood PressureChemotherapyPoor Wound HealingPacemaker / DefibrilatorImplanted Cord / Bladder StimulatorExcessive Thirst or Urination
Present Health Concerns
In Order of Importance, list the health problems you are most interested in having corrected:
1. 
2. 
3. 
4.
List approximately how long you have noticed these problems in your life:
1. 2. 3. 4.
Is there a certain time of the day any of these pains are worse? Explain.
What have you used for these issues?

GabapentinNeurontinLyricaCymbaltaPhysical TherapyPain MedsAleveTylenolIbuprofenMotrinChiropracticMassage TherapyInjectionsCreamsOther
Explain how your balance/walking ability is affected, if applicable.
What do you think is causing your problem?
List the doctor(s) you have seen for these problems and treatment you received
Have your symptoms:

ImprovedStayed The SameWorsened
What makes things better?*
What makes things worse?*
Describe your symptoms, checking all that apply

AchingTingling/electricDead feelingStabbingPins/needlesCold hands/feetSharpHeavyCrampingTired/fatiguedHot sensationSwellingNumbnessThrobbingBurningOther
Is this condition interfering with any of the following? Check all that apply.

SleepWorkDaily ActivitiesRecreational ActivitiesWalkingStandingOther
How much do you smoke/vape per day? List Marijuana too. Put 0 if none.
How many alcoholic drinks per week do you consume. Put 0 if none.
What exercise do you do? Put 0 if none.
How would you rate your pain in the last week?*

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst Possible Pain
If you had to accept some level of pain after completion of treatment, what would be an acceptable level?*

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst Possible Pain
List ALL allergies/sensitivities to medicine, food, or other items. Explain what your reactions are to each.
EX: Shrimp gives me hives.
List: Medications, Dose, Time Daily
EX: Chirosol 50mg 2x/d.
List Supplements (vitamins, herbs, homeopathics, etc.)
Confidentiality

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 _______________________
Should be Empty:

Neuropathy Consult ROF

Your Information

Review of Symptoms

Present Health Concerns

Confidentiality