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Patient name: Date of birth: This pain started on: I have: The pain is:The back pain started after:BurningSharpA car accidentItchingDullA fallPins and needlesConstantAnother AccidentNumbnessthrobbingLifting somethingThe pain is in the middle of my back:YesNoThe pain can radiate:Right LeftThe pain is in my RIGHT:BackButtockKneeCalfFootThe pain is in my LEFT:BackButtockKneeCalfFootThis has gotten worse since it started: Yes NoActivities that make the pain worse: Activities or treatments that make the pain better:My LEFT leg feels weak:YesNoMy RIGHT leg feels weak:YesNoWhen I wipe my bottom after going to the bathroom, it feels normalYesNoI wet my pantsYesNoI soil my pantsYesNoI can achieve or maintain an erectionYesNoI have normal sexual functionYesNoDate of last MRI of my back:Facility or Ordering Physician:Date of last Surgery on my back: Facility or Ordering Physician:Surgery was for: I have been on medications for back pain:YesNoMedications:I have had injections in my backYesNoI have been to physical therapyYesNoI have had previous episodes of back painYesNoThe information provided on this questionnaire is correct to the best of my knowledge.__________________________________________ _____________Signature Date/Time ................
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