New Patient Summary

Patient Summary

In order to schedule an appointment with Dr. Williams, he requests that each patient complete this form. Please answer the questions below and provide a detailed patient summary of your condition from the very start of the problem up to the present time. The summary should be as detailed as possible yet limited to just the information that is relevant to the specific problem you are coming to Dr. Williams for. The summary should be written down in chronological order as you have experienced them. Avoid dramatic or emotional embellishment of your story. Above all, be sure to give a detailed, accurate description of where in your body your pain and other symptoms are located throughout your story. Peripheral nerves go to specific places. If you are inaccurate with your descriptions of where your pain is located, it could result in the wrong nerve(s) being identified which delays correct diagnosis and treatment. All records will be required before scheduling an appointment and must be uploaded to this form.
Full Name*

First NameMiddle InitialLast Name
Date of birth?*

MonthDayYear
Date
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
How did you hear about us?*

Search engine (google, yahoo, etc.)FacebookFriend/family memberAnother physician
If you were referred by a physician, which physician?*
If they wrote a referral, please ask them to fax it to 410-337-5520
What kind of insurance do you plan to use?*
If you have already spoken with our office and it has been determined that we do not take your insurance, please list "self pay" here.
Biological sex*

FemaleMale
Height and weight*
What SIDE of your body is the pain located?*

RIGHT sideLEFT sideBOTH sides
What area is your primary concern?*

HeadFaceNeckShoulderUpper ArmLower ArmWristHandFinger(s)ChestBackStomach/AbdomenGroinGenitalsButtockHipUpper LegKneeLower LegAnkleFootToe(s)
What TYPE of pain are you experiencing?*

Burning painSharp painShooting painStabbing painCramp-like painDull/aching painNumbnessTinglingOther
Is the pain in your thigh ONLY on the outer part of your thigh?*

YesNo
Have you been diagnosed with Meralgia Paresthetica?*

YesNo
Have you had a nerve block of the Lateral Femoral Cutaneous Nerve (LFCN)?*

YesNo
Were you numb/pain free for a few hours directly after the block?*

YesNo
Additional comments about the block(s)
Optional
Have you been told by a doctor that you do not have any issues with your spine?*

YesNo
*If you have not already done so, you will need to have an MRI of your Lumbar Spine (lower back) BEFORE scheduling an appointment to rule out a spine issue*
Have you been told by a doctor that you do not have any issues with your hip?*

YesNo
Have you been told / suspect you have Occipital Neuralgia?

YesNo
*If you have not already done so, you will need to have two separate successful occipital nerve blocks BEFORE scheduling an appointment*

This can be done by a pain management team. If the pain did not go away for 4-8 hours giving you blissful relief AND the back of your head did not go numb, the nerve block was not successful.
Do you have a Foot Drop?*

YesNo
******** FOOT DROP ********
**Please note- forms WILL NOT be reviewed if you do not complete the next question**

This is an extremely important piece of information Dr. Williams requires
Use the camera icon below to take/upload a photo and you can then draw and annotate on the photo below. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
Please use the tools below to draw on the photos. Please mark SPECIFICALLY where the pain is. If the pain travels, please place an "X" where it starts with an arrow in the direction that it travels. **Again, please be specific***
When did the pain start? (No matter how your problem started, please give as accurate an estimate on the date it started as possible. This should be the date or period when you noticed the problem for the very first time.)*
How did the pain start?(If there was some type of accident, trauma or surgery that caused your problem or made the problem worse, be as detailed as possible in describing the events.) *PLEASE BE SPECIFIC* *
Did your pain start after a trauma (i.e. fall, accident, injury) or surgery*

Trauma (i.e. fall, accident, injury)SurgeryNeither
What was the trauma or surgery? *PLEASE BE SPECIFIC* *
****IF THIS HAPPENED AS A RESULT OF SURGERY, WE NEED THE OPERATIVE REPORT FROM THAT SURGERY****
***For all questions below, please be SPECIFIC and detailed in your responses***
Describe how your pain felt when it first started and how it progressed or changed over time *IN CHRONOLOGICAL ORDER*. (As you write your summary, please include brief descriptions of anything that made your problem better or worse – please be detailed when describing the changes that resulted. Please end your story with a current summary of all your various pain complaints and specifically where all pain is located. This symptom summary should reflect what you are currently experiencing on a day-to-day basis. Please be as clear and concise as possible while also being specific.) *
What specifically are your top priorities for the problem you wish to see Dr. Williams for? *Please do not write "relief of pain", be specific in what you are hoping Dr. Williams to accomplish (for example: 'I want the burning on the top of my foot to go away', etc.)*
If Dr. Williams deems surgery necessary, how soon are you hoping to schedule a surgery with him?*

As soon as possibleLess than 3 monthsMore than 3 monthsI'm not looking to have surgery
As Dr. Williams is a surgeon, he is going to have surgical options for you. If you're not looking to have surgery, what is your goal when seeing Dr. Williams?*
*If your goal is medication management, Dr. Williams is not the right physician for you*

Patient Summary

FOOT DROP

Please note- forms WILL NOT be reviewed if you do not complete the next question

History of treatment

We cannot accept screenshots, or photos of records, we need clear PDF documents for each record. You can save this form and come back to it later if needed.

An appointment will not be scheduled until your faxed records have been received

Patient Summary

******** FOOT DROP ********

**Please note- forms WILL NOT be reviewed if you do not complete the next question**

History of treatment

We cannot accept screenshots, or photos of records, we need clear PDF documents for each record. You can save this form and come back to it later if needed.

**An appointment will not be scheduled until your faxed records have been received**

FOOT DROP

Please note- forms WILL NOT be reviewed if you do not complete the next question

An appointment will not be scheduled until your faxed records have been received