Follow-up Visit Form
Are you the patient?
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Yes
No
If you're answering for an adult, please let us know who you are. Please answer all following questions on behalf of the patient. Anytime you see "You" in the question please answer the question related to the patient.
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Patient's spouse
Patient's parent or step-parent
Patient's legal guardian or representative
Other: relative authorized to act on behalf of the patient
Other: caregiver (non-family) authorized to act on behalf of the patient
Enter the first and last name of the person completing this information on behalf of the patient
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First Name
Last Name
Patient's Name
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First Name
Middle Name
Last Name
Patient's Date of Birth
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Month
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Day
Year
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Today's Date
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Month
-
Day
Year
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Please enter the date (or approximate date) of your most recent COVID-19 vaccine dose:
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Month
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Day
Year
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Reason For Your Visit:
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Medication Refill
Medication change
New Pain
Post-Procedure Assessment
Review MRI/CT Results
Review Test Results
Other : ___________________
What is the name and address of your preferred pharmacy?
Location of the pain that you are here for:
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You may also help us visualize the location of your pain by shading the body part in the image provided below.
Are any of these pains new since your last visit?
Yes
No
If yes, please explain:
Where does your pain radiate into?
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My pain does not radiate
Right leg
Right arm
Left leg
Left arm
Other
How do you describe your pain?
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Aching
Cramping
Numbness
Hot/Burning
Tingling/Pins and Needles
Throbbing
Shock-like
Shooting
Spasming
Dull
Tiring/Exhausting
Stabbing/Sharp
Squeezing
Other : ___________________
What word best describes the frequency of your pain?
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Constant
Intermittent (comes & goes)
Changes in severity but always present
When is your pain worse?
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Mornings
During the day
Evenings
Nights
Middle of the night
Describe the severity of your pain at it's worst (0 as no pain and 10 as worst pain you can imagine):
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0
1
2
3
4
5
6
7
8
9
10
Describe the severity of your pain today (0 as no pain and 10 as worst pain you can imagine):
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0
1
2
3
4
5
6
7
8
9
10
Are you currently treating your pain with any of the following conservative treatments?
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Injections for pain
Manipulation
Home exercises
Exercises in physical therapy
Pain medications
Muscle relaxant pills
Aspirin/Anti-inflammatory pills
Heat/Ice
Cognitive-behavioral therapy
Chiropractic care
Acupuncture
Aquatic therapy
Dry Needling
Massage therapy
Nothing
Other : ___________________
What are you taking for your pain?
Ex. Hydrocodone, Percocet, NSAIDs
How much relief has pain medication provided?
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
No Relief
My medications help improve my functioning and quality of life.
Agree
Disagree
Which aspects of functioning and quality of life do your medications improve? (select all that apply)
Activities of daily living (ADLs)
Work
School
Home duties
Recreational activities
Other
Mark the following medicine side-effects you are experiencing, if any:
Confusion
Constipation
Dizziness
Drowsiness
Dry Mouth
Nausea
Vomiting
Weight Gain
I do not have any adverse side effects from current medications
Other
Do you have full control of your bladder and bowels?
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Yes
No: Which one? ________________
What activities make it worse?
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Exercise (during)
Exercise (after)
Sitting
Driving
Standing
Walking
Bending forward
Bending backward
Coughing
Sneezing
Reaching
Lifting
Other : ___________________
What reduces the pain?
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Lying down
Sitting
Standing
Walking
Injections for Pain
Manipulation
Home exercises
Exercises in physical therapy
Pain pills
Muscle relaxant pills
Aspirin/Anti-inflammatory pills
Heat / Ice
Nothing
Other : ___________________
Which of the following activities does your pain significantly interfere with?
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Activities of daily living (ADLs)
Work
School
Home duties
Recreational activities
No functional impairment
Have you visited the emergency room since your last visit?
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No
Yes: When and where? ______________
Have you had any X-rays, MRIs, CT scans since your last visit?
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No
Yes: When and where? ______________
Have you had any operations or procedures since your last visit?
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No
Yes: Please describe briefly: ______________
Have you been diagnosed with any new medical problems since your last visit?
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No
Yes: Please describe briefly: ______________
COMPLETE THE NEXT SECTION ONLY IF YOU ARE HERE AFTER A PROCEDURE:
Which option describes your pain relief produced by the last injection?
Up to 29%
30 - 49%
50 - 69%
70 - 89%
90 - 100%
No Relief
Did the last injection result in functional improvement?
Yes
No
For this site, how long was your pain relief and functional improvement achieved?
Less than one (1) week
1 to 2 weeks
Three (3) weeks or longer
Have you continued with conservative therapy since the last injection?
Yes
No
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