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Conditions
Treatments
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Forms
Blog
Contact
Follow Up
Follow Up
Date
MM slash DD slash YYYY
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Primary Care Provider
Pharmacy
Medications
Medication Side Effects
Any side effects of prescribed medications since last visit?
Medication Changes
Any changes in medications since last visit?
Medication Refill
Do you need any medications refilled?
List Allergies:
Allergy to contrast dye?
Yes
No
Blood Thinners:
Yes
No
If yes, what?
Antibiotics:
Yes
No
If yes, what?
Are you pregnant?
Yes
No
Injection
Any recent injections?
Yes
No
Relief
Select the percentage of how much relief procedure provided
0% (None)
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% (Complete Relief)
Relief
How long did you get relief from previous procedure? (# of days, months, years)
Improved Activities
What activities, if any, have improved with current treatment (please be as specific as possible):
Tests or Surgeries
Diagnostic Tests
Any diagnostic tests or surgeries since last visit?
Health History
Diagnostic Tests
Any changes in your health since your last visit?
Are you experiencing
Are you experiencing: fever, chills, bladder/bowel incontinence or retention (new/old), weakness (new/old), tingling (new/old), numbness (new/old), constipation, nausea, changes in alertness?
Tests or Surgeries
Tests or Surgeries
Any diagnostic tests or surgeries since last visit?
Where Is Your Pain?
Select an Area
Head (front left)
Head (front center)
Head (front right)
Head (back left)
Head (back center)
Head (back right)
Shoulder (left)
Shoulder (right)
Bicep (left)
Bicep (right)
Forearm (left)
Forearm (right)
Chest (left)
Chest (middle)
Chest (right)
Upper Back (left)
Upper Back (middle)
Upper Back (right)
Abdomen (left)
Abdomen (middle)
Abdomen (right)
Lower Back (left)
Lower Back (middle)
Lower Back (right)
Thigh (front left)
Thigh (back left)
Thigh (front right)
Thigh (back right)
Calf (front left)
Calf (back left)
Calf (front left)
Calf (back left)
Foot (top left)
Foot (bottom left)
Foot (top right)
Foot (bottom right)
What are you feeling in this area?
Pain
Numbness/Tingling
Spasm/Cramp
Words that describe the pain in this area
Aching
Boring or drilling
Burning
Colicky
Cramping
Crushing
Dull
Gnawing
Heaviness
Nagging
Penetrating
Pins and Needles
Pressure
Raw
Sharp
Shock-like
Shooting
Sore
Stabbing
Stinging
Throbbing
Tightness
Other area of pain (if applicable)
Select an Area
Head (front left)
Head (front center)
Head (front right)
Head (back left)
Head (back center)
Head (back right)
Shoulder (left)
Shoulder (right)
Bicep (left)
Bicep (right)
Forearm (left)
Forearm (right)
Chest (left)
Chest (middle)
Chest (right)
Upper Back (left)
Upper Back (middle)
Upper Back (right)
Abdomen (left)
Abdomen (middle)
Abdomen (right)
Lower Back (left)
Lower Back (middle)
Lower Back (right)
Thigh (front left)
Thigh (back left)
Thigh (front right)
Thigh (back right)
Calf (front left)
Calf (back left)
Calf (front left)
Calf (back left)
Foot (top left)
Foot (bottom left)
Foot (top right)
Foot (bottom right)
What are you feeling in this area?
Pain
Numbness/Tingling
Spasm/Cramp
Words that describe the pain in this area
Aching
Boring or drilling
Burning
Colicky
Cramping
Crushing
Dull
Gnawing
Heaviness
Nagging
Penetrating
Pins and Needles
Pressure
Raw
Sharp
Shock-like
Shooting
Sore
Stabbing
Stinging
Throbbing
Tightness
Other area of pain (if applicable)
Select an Area
Head (front left)
Head (front center)
Head (front right)
Head (back left)
Head (back center)
Head (back right)
Shoulder (left)
Shoulder (right)
Bicep (left)
Bicep (right)
Forearm (left)
Forearm (right)
Chest (left)
Chest (middle)
Chest (right)
Upper Back (left)
Upper Back (middle)
Upper Back (right)
Abdomen (left)
Abdomen (middle)
Abdomen (right)
Lower Back (left)
Lower Back (middle)
Lower Back (right)
Thigh (front left)
Thigh (back left)
Thigh (front right)
Thigh (back right)
Calf (front left)
Calf (back left)
Calf (front left)
Calf (back left)
Foot (top left)
Foot (bottom left)
Foot (top right)
Foot (bottom right)
What are you feeling in this area?
Pain
Numbness/Tingling
Spasm/Cramp
Words that describe the pain in this area
Aching
Boring or drilling
Burning
Colicky
Cramping
Crushing
Dull
Gnawing
Heaviness
Nagging
Penetrating
Pins and Needles
Pressure
Raw
Sharp
Shock-like
Shooting
Sore
Stabbing
Stinging
Throbbing
Tightness
Average Pain Intensity
Select the number to indicate your average pain intensity over the past week:
Select a number
0 (None)
1 (Mild)
2 (Mild)
3 (Mild)
4 (Moderate)
5 (Moderate)
6 (Moderate)
7 (Severe)
8 (Severe)
9 (Severe)
10 (Most)
Pain Intensity Right Now
Select the number to indicate your average pain intensity right now:
Select a number
0 (None)
1 (Mild)
2 (Mild)
3 (Mild)
4 (Moderate)
5 (Moderate)
6 (Moderate)
7 (Severe)
8 (Severe)
9 (Severe)
10 (Most)
Pain Medications
Select the percentage of how much pain relief medication(s) have provided (if applicable)
Select a number
0% (None)
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% (Complete relief)
Pain Interference (General Activity)
Select the number that describes how, during the past week, pain has interfered with your general activity.
Select a number
0 (None)
1 (Mild)
2 (Mild)
3 (Mild)
4 (Moderate)
5 (Moderate)
6 (Moderate)
7 (Severe)
8 (Severe)
9 (Severe)
10 (Most)
Pain Interference (Enjoyment of Life)
Select the number that describes how, during the past week, pain has interfered with your enjoyment of life.
Select a number
0 (None)
1 (Mild)
2 (Mild)
3 (Mild)
4 (Moderate)
5 (Moderate)
6 (Moderate)
7 (Severe)
8 (Severe)
9 (Severe)
10 (Most)
Little interest in doing things
Over the past week, how often have you felt little interest or pleasure in doing things?
Select a number
0 (Not at all)
1
2
3 (Nearly every day)
Little interest in doing things
Over the past week, how often have you felt down, depressed, or hopeless?
Select a number
0 (Not at all)
1
2
3 (Nearly every day)
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