Do you take any type of diet pill?
 
 
What?  
 
Have you had any serious illnesses in the past? If so, please list year and type of illness:
Type
Year  
Type
Year  
Type
Year  
Type
Year  
Type
Year  
 

SYMPTOMS

Neck pain
 
 
Back pain
 
 
Arm pain
 
 
 
 
 
Leg pain
 
 
 
 
 
 

CONSERVATIVE TREATMENT HISTORY

Physical Therapy
 
 
 
Location  
How long  
 
Traction
 
 
 
Pain Management
 
 
 
Location  
How long  
 
Epidurals/Facet Blocks
 
 
How many times?  
 
Injections/Implantable
 
 
Type?  
 
Previous Back/Neck Surgery
 
 
 
Procedure type:  
 
location:  
 
Date:  
 

PAIN MEDICATIONS

Prescription medications  
 
Dose  
 
How often Taken  
Prescription medications  
 
Dose  
 
How often Taken  
Prescription medications  
 
Dose  
 
How often Taken  
Prescription medications  
 
Dose  
 
How often Taken  
Prescription medications  
 
Dose  
 
How often Taken  
Prescribing MD:  
Primary Care MD:  
Phone:  
Pain Management MD:  
Phone:  
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 1736
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