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. All records will be required before scheduling an appointment and must be uploaded to this form.
Full Name
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First Name
Middle Initial
Last Name
Date of birth?
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/
Month
/
Day
Year
Date
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
How did you hear about us?
*
Search engine (google, yahoo, etc.)
Facebook
Friend/family member
Another physician
If you were referred by a physician, which physician?
*
If they wrote a referral, please ask them to fax it to 410-337-5520
What kind of insurance do you plan to use?
*
If you have already spoken with our office and it has been determined that we do not take your insurance, please list "self pay" here.
What area is your primary concern?
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Head
Face
Neck
Shoulder
Upper Arm
Lower Arm
Wrist
Hand
Finger(s)
Chest
Back
Stomach/Abdomen
Groin
Genitals
Buttock
Hip
Upper Leg
Knee
Lower Leg
Ankle
Foot
Toe(s)
What SIDE of your body is the pain located?
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RIGHT side
LEFT side
BOTH sides
Biological sex
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Female
Male
Height and weight
*
**Please note- forms WILL NOT be reviewed if you do not complete the next question**
This is an extremely important piece of information Dr. Williams requires
Use the camera icon below to take/upload a photo and you can then draw and annotate on the photo below. 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. **Again, please be specific**
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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. **Again, please be specific**
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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. **Again, please be specific**
*
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. **Again, please be specific**
*
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. **Again, please be specific**
*
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. **Again, please be specific**
*
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. **Again, please be specific**
*
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.)
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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.) *PLEASE BE SPECIFIC*
*
Did your pain start after a trauma (i.e. fall, accident, injury) or surgery
*
Trauma (i.e. fall, accident, injury)
Surgery
Neither
What was the trauma or surgery? *PLEASE BE SPECIFIC*
*
****IF THIS HAPPENED AS A RESULT OF SURGERY, WE NEED THE OPERATIVE REPORT FROM THAT SURGERY****
What TYPE of pain are you experiencing?
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Burning pain
Sharp pain
Shooting pain
Stabbing pain
Cramp-like pain
Dull/aching pain
Numbness
Tingling
Other
***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 while also being specific.)
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Have you been diagnosed with Meralgia Paresthetica?
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Yes
No
Have you had a nerve block of the Lateral Femoral Cutaneous Nerve (LFCN)?
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Yes
No
Were you numb/pain free for a few hours directly after the block?
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Yes
No
Additional comments about the block(s)
Optional
Have you been told by a doctor that you do not have any issues with your spine?
*
Yes
No
What specifically are your top priorities for the problem you wish to see Dr. Williams for? *Please do not write "relief of pain", be specific in what you are hoping Dr. Williams to accomplish (for example: 'I want the burning on the top of my foot to go away', etc.)
*
If Dr. Williams deems surgery necessary, how soon are you hoping to schedule a surgery with him?
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As soon as possible
Less than 3 months
More than 3 months
I'm not looking to have surgery
As Dr. Williams is a surgeon, he is going to have surgical options for you. If you're not looking to have surgery, what is your goal when seeing Dr. Williams?
*
*If your goal is medication management, Dr. Williams is not the right physician for you*
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History of treatment
Please note, no appointments will be scheduled until we have received all records required. We cannot accept screenshots, or photos of records, we need clear PDF documents for each record. You can save this form and come back to it later if needed.
Please select the following that you have tried ONLY as it relates to the pain you would like to be seen for.
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MRI
MRN (MR Neurography)
EMG
X-ray
Medications
Physical therapy
Steroid injection
Nerve block/injection
Surgery
None of these
Other
Reports are required to schedule an appointment. Please choose one of the following:
*
I am able to upload the imaging report(s)
I will have the imaging report(s) faxed to 410-337-5520
Upload ALL imaging reports here
*
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Reports are required to schedule an appointment. Please choose one of the following:
*
I am able to upload the EMG report(s)
I will have the EMG report(s) faxed to 410-337-5520
Upload EMG report here
*
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of
What type of injection(s) were performed?
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Did any of the injection(s) help - even for a short period of time?
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Yes
No
How long did the nerve block help? (be specific, please! i.e. how many hours/days/weeks)
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Reports are required to schedule an appointment. Please choose one of the following:
*
I am able to upload the injection report(s)
I will have the injection report(s) faxed to 410-337-5520
Upload nerve block reports here. Please only include reports for nerve blocks that helped for a few hours or more.
*
Browse Files
Cancel
of
Reports are required to schedule an appointment. Please choose one of the following:
*
I am able to upload the operative report(s)
I will have the operative report(s) faxed to 410-337-5520
Upload operative report(s) here
*
Browse Files
Cancel
of
**An appointment will not be scheduled until your faxed records have been received**
Our fax number is 410-337-5520
Any additional records you have can be attached here:
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of
Additional major medical problems (if none, enter N/A)
*
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