Peripheral Nerve Stimulation Evaluation Form
Please complete this form to assist in evaluating candidacy for peripheral nerve stimulation. All responses are for clinical assessment only.
Patient Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Physician or Provider
*
Primary Diagnosis or Condition
*
Location of Pain or Symptoms
*
Please Select
Upper limb (arm, hand)
Lower limb (leg, foot)
Trunk/torso
Face or head
Multiple areas
Other
Describe the Nature and Duration of Pain/Symptoms
*
Prior Treatments Attempted (select all that apply)
*
Physical therapy
Medications
Nerve blocks
Surgery
Other neuromodulation
Other
Current Medications (list all relevant)
Functional Impact (how symptoms affect daily activities)
*
Goals for Peripheral Nerve Stimulation
*
Submit Evaluation
Should be Empty: