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10678 FM 346, Flint, TX 75762
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Neuropathy Intake Form
Name
Your occupation
address
City
State
Zip Code
Phone
email
Date of birth
Spouse Name
Spouse Phone Number
Retired
Select One
Yes
No
Review of Symptoms
Foot Pain
Hand Pain
Low Back Pain
Neck Pain
Foot Numbness
Hand Numbness
Diabetes
High Cholesterol
High Blood Pressure
Pacemaker / Defibrillator
Herniated Disc
Bulging Disc
Spinal Stenosis
Degenerative Disc
Vascular Problems
Leg Pain
Morton's Neuroma
Cancer
Chemotherapy
Implanted Cord / Bladder Stimulator
Arthritis in Hands
Arthritis in Feet
Plantar Fascilitis
Sciatica
Pinched Nerve
Poor Circulation
Joint Replacement
Foot Surgery
Poor Wound Healing
Excessive Thirst or Urination
Present Health Condition
In order of importance, list the health problems you are most interested in getting corrected:
1.
2.
3.
4.
Is there a certain time of day any of these problems are better or worse?
Is your balance/walking ability affected? If yes, please describe
List approximately how long you have noticed these problems in your life:
1.
2.
3.
4.
List the things you have used for these problems:
Gabapentin
Neurontin
Lyrica
Cymbalta
Physical Therapy
Pain Medications
Aleve
Tylenol
Ibuprofen
Motrin
Chiropatric
Massage Therapy
Injections
Creams
What do you think is causing your problem?
Name of all doctors you have seen for these problems and treatment you received
Have your symptoms:
Select One
Improved
Worsened
Stayed the Same
List anything that makes your condition worse
List anything that makes your condition better
How would you describe the symptoms? Please check ALL that apply
Aching Pain
Stabbing Pain
Sharp Pain
Tiredness
Numbness
Tingling / Electric Shocks
Pins & Needles Pain
Heavy Feeling
Hot Sensation
Throbbing Pain
Dead Feeling
Cold Hands / Feet
Cramping
Swelling
Burning
Is this condition interfering with any of the following?
Sleep
Recreational Activities
Work
Walking
Daily Activities
Standing
Social History
Do you smoke?
Select One
Yes
No
If yes, how many cigarettes daily?
Do you drink?
Select One
Yes
No
If yes, how many drinks per week?
Do you exercise?
Select One
Yes
No
If yes, please describe type and how often
Current Pain Levels
How would you rate your pain in the last week?
1 - No Pain
2
3
4
5
6
7
8
9
10 - Worst Possible Pain
If you had to accept some level of pain after completion of treatment, what would be an acceptable level?
1 - No Pain
2
3
4
5
6
7
8
9
10 - Worst Possible Pain
Previous Health Conditions
This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization, unless you sign here indicating that we can release copies by your verbal request.
Your Full Name
Date
Please give name, address and office phone number of your primary care physician.
Name
Phone
Address
When were you last seen there?
May we send them updates on your treatment/condition?
Select One
Yes
No
List ALL allergies/sensitivities to medication, food, and other items:
Items you react to:
Reaction:
List the prescription drugs you are currently taking:
Name
Dose (mg or IU)
Time Daily
List all nutrition supplements (vitamins, herbs, homeopathics, etc.) as above
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