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COVID 19 pre-screening questionnaire
COVID19 screening at visit (***MASKS are required in our clinic)
Follow up Questionnaire
New Patient Form
New Patient Pain Questionnaire
Follow up Questionnaire
Last name
*
First name
*
Date of birth
*
Date of visit
*
Where is your pain located?
PAIN LEVEL: On a scale of 1-10 (with 10 being the most pain), what is your pain level?
Is your pain....
*
Constant
Intermittent
Unchanged
Worse
Better
Describe how your pain feels:
*
Sore
Achy
Throbbing
Stabbing
Burning
None of the above
If you checked "none of the above," please describe how your pain feels here:
What treatment have you tried so far?
*
Physical therapy
TENS
Medications
Heating pad
Ice
Injections
Exercise
Epidural injections
Surgery
Massage
Acupuncture
Chiropractor
None of the above
If none of the above, describe what treatments you have tried so far:
What makes the pain worse?
What makes your pain better?
Review of systems
Musculoskeletal
Joint pain or swelling
*
No
Yes
Redness
*
No
Yes
Restricted motion of joint
*
No
Yes
Neurological
Numbness or tingling?
*
No
Yes
Loss of sensation?
*
No
Yes
Loss of feeling
Burning?
*
No
Yes
Gastrointestinal
Heartburn?
*
No
Yes
Medications (prescription and over the counter):
*
* Required field
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