Follow Up Form
Neurosurgery Spine
Patient Name
*
First Name
Last Name
Date of Birth
Please select a month
January
February
March
April
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October
November
December
Month
Please select a day
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Day
Please select a year
2024
2023
2022
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2019
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1925
1924
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1921
1920
Year
When did your pain first start? (date or approx. month/year):
When did it worsen? (date and event, if applicable)
Rate the severity of your pain on a scale from 1 to 10, with 1 being the least painful and 10 being the most severe:
Type of pain (select all that apply):
Aching
Burning
Cramps
Dull
Numbness
Sharp
Shooting
Stiffness
Swelling
Tingling
Throbbing
Does the pain interfere with any of the following activities of daily living? (Select all that apply)
Bathing
Dressing
Feeding
Food preparation
Grooming
Housework
Sleep
Toilet hygiene
Work
How often are you having pain?
Please Select
Constant
It comes and goes
Activities or movements that are painful to perform: (select all that apply)
Bending
Lying down
Sitting
Standing
Walking
In the past 6 months, have you received any formal therapy for this condition?
Please Select
Yes
No
If yes, when?
Do you perform home exercises/stretches for this condition?
Please Select
Yes
No
Have you received an Epidural Steroid Injection for this condition?
Please Select
Yes
No
If yes, when?
What percentage relief did the injection provide?
For how long? (hours, days, weeks, months)
When did the pain return?
-
Month
-
Day
Year
Date
Have you tried any of the following for pain relief (check all that apply)?
Did this provide relief?
Name of Medication
Heat
Yes
No
Ice
Yes
No
Over the Counter Medications
Yes
No
Prescription
Yes
No
Are you claustrophobic (fear of being in a closed/confined place)?
Please Select
Yes
No
Do you have metal in your body?
Please Select
Yes
No
If yes, where?
Signature
Continue
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