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.
Full Name*

First NameMiddle InitialLast Name
Date of birth?*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
How did you hear about us?*

Search engine (google, yahoo, etc.)Our websiteFacebookFriend/family memberAnother physician
If you were referred by a physician, which physician?*
What kind of insurance do you plan to use?*
What area is your primary concern?*

HeadFaceNeckShoulderUpper ArmLower ArmWristHandFinger(s)ChestBackStomach/AbdomenGroinGenitalsButtockHipUpper LegKneeLower LegAnkleFootToe(s)
What SIDE of your body is the pain located?*

RIGHT sideLEFT sideBOTH sides
Biological sex*

FemaleMale
Height and weight*
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.
*
*
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.)*
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?*
****IF THIS HAPPENED AS A RESULT OF SURGERY, WE NEED THE OPERATIVE REPORT FROM THAT SURGERY****
What TYPE of pain are you experiencing?*

Burning painSharp painShooting painStabbing painCramp-like painDull/aching painNumbnessTinglingOther
***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.)*
What specifically are your top priorities for the problem you wish to see Dr. Williams for?*
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
History of treatment (Please select the following that you have tried ONLY as it relates to the pain you would like to be seen for. Please be prepared to have the reports sent to us should Dr. Williams require additional review or they can be attached at the bottom of the form.)*

MRIMRN (MR Neurography)EMGX-rayMedicationsPhysical therapySteroid injectionNerve blockSurgeryNone of theseOther
When and what imaging center was the MRI performed at? *
***WE WILL NEED THE REPORT FROM THIS***
When and what imaging center was the MRN performed at?*
***WE WILL NEED THE REPORT FROM THIS***
When and where was the EMG performed? *
***WE WILL NEED THE REPORT FROM THIS***
When and what imaging center was the Xray performed at? *
***WE WILL NEED THE REPORT FROM THIS***
When was/were the injection(s) performed and by what physician? *
***WE WILL NEED THE RECORDS FROM THIS***
What Surgery was performed? When? By What physician?*
***PLEASE NOTE: If you have the records in your possession, they can be attached below, or please have them faxed to 410-337-5520. We will need these PRIOR to Dr. Williams reviewing your form.***
Any records you have can be attached here:

Browse Files

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Additional major medical problems (if none, enter N/A)*
Should be Empty:

Patient Summary

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.