04. Follow-up Visit Form

Follow-up Visit Form
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Today's Date *

Month Day Year
Date
Reason For Your Visit: *

Medication Refill Medication change New Pain Post-Procedure Assessment Review MRI/CT Results Review Test Results Other : ___________________
Where is your pain located? *
You may also help us visualize the location of your pain by shading the body part in the image provided below.
How do you describe your pain? *

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? *

Constant Intermittent (comes & goes) Changes in severity but always present
When is your pain worse? *

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): *

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): *

0 1 2 3 4 5 6 7 8 9 10
Are you currently treating your pain with any of the following conservative treatments? *

Injections for pain Manipulation Home exercises Exercises in physical therapy Pain pills Muscle relaxant pills Aspirin/Anti-inflammatory pills Heat/Ice 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. *

Yes No
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
Do you have full control of your bladder and bowels? *

Yes No: Which one? ________________
What activities make it worse? *

Exercise (during) Exercise (after) Sitting Driving Standing Walking Bending forward Bending backward Coughing Sneezing Reaching Lifting Other : ___________________
What reduces the pain? *

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 are you not able to perform? *

Activities of daily living (ADLs) Work School Home duties Recreational activities No functional impairment
Have you visited the emergency room since your last visit? *

No Yes: When and where? ______________
Have you had any X-rays, MRIs, CT scans since your last visit? *

No Yes: When and where? ______________
Have you had any operations or procedures since your last visit? *

No Yes: Please describe briefly: ______________
Have you been diagnosed with any new medical problems since your last visit? *

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
Should be Empty:

Follow-up Visit Form

COMPLETE THE NEXT SECTION ONLY IF YOU ARE HERE AFTER A PROCEDURE: