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Pain Management - Patient Intake Form
Visit Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
ANS: NAME
Date of Birth
*
-
Month
-
Day
Year
Date
Reason for your visit today
*
Injection Consult
General follow up
Post procedure visit
Imaging Review
Other
ANS: Reason for your visit today
Symptoms you are experiencing today (Check all that apply)
*
Low back pain (lumbar spine)
Mid back pain (thoracic spine)
Neck back pain (cervical spine)
Pain in the leg (sciatica) - Right
Pain in the leg (sciatica) - Left
Pain in the arm (radiculopathy) - Right
Pain in the arm (radiculopathy) - Left
Numbness in arms/ hands
Numbness in legs/feet
Decreased walking tolerance
Clumsiness in hands
Loss of balance when wlking
Other
ANS: Symptoms you are experiencing today (Check all that apply)
Pain Assessment: Describe severity of your pain right now.
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
Mark X the area you feel pain right now.
*
Circle the area you feel pain right now.
*
How would you characterize your pain?
*
What makes the pain better?
*
What makes the pain worse?
*
Are you here for HEADACHES?
*
Please Select
YES
NO
Did any of your medications change since last visit?
*
Please Select
YES
NO
Specify medications
Did you stop taking any medications your doctor prescribed due to side effects?
*
Please Select
YES
NO
Specify Medications stopped and side effects
Rows
Medications
Side Effects
1
2
3
4
Did you have imaging since your last visit?
*
Please Select
YES
NO
List imaging studies done
Ans: List imaging studies done
Back
Next
Did you undergo any of the following below treatments since your last visit
Physical Therapy
*
Please Select
YES
NO
Name of PT
Date
Chiropractor
*
Please Select
YES
NO
Name of Chiropractor
Date
Acupuncture
*
Please Select
YES
NO
Date
Massage Therapy
*
Please Select
YES
NO
Date
Any change in your work status since your last visit?
*
Please Select
YES
NO
Specify
*
Return to full duty
Limited duty
Out of work
Other
Date of change in work status
*
-
Month
-
Day
Year
Date
Ans: Specify - work status
Patient Signature
*
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