Follow-Up Medical Questionnaire



Follow-Up Medical Questionnaire Pharmacy:____________________ Provider: ____64598555461002000034594806413502000088455564135020000_______________378333050800020000Date: ___________ Patient: _________________________ DOB: ____________ PCP: _____________________1.Is there a new problem that was not evaluated at your last visit? □ Y □ N If so, what is it? _____________2.How long has it been since your last visit? ______ □ Days □ Weeks □ Months3.Since your last visit, are you: □ Better □ Worse □ Same4.On a scale of 0 - 100%, how much better are you now? If no better, put 0% _____%5.On a scale of 0 – 10 (10 being the worst) how severe is your pain now (circle) 0 1 2 3 4 5 6 7 8 9 106.On a scale of 0 – 10 how severe is your pain on medication (circle) 0 1 2 3 4 5 6 7 8 9 107.What is the quality of the pain? □ Sharp □ Dull □ Stabbing □ Throbbing □ Aching □ Burning8.The pain is now □ constant □ comes and goes (intermittent) Does it wake you from sleep? □ Y □ N 9.Do you have □ Numbness □ Tingling □ Weakness □ Loss of control of bowel or bladder □ None10.What medications are you still taking for this condition □ NoneAnti-inflammatory ___________________Narcotic (pain killer) _________________11.Use check box below to show what treatment was done at or since your last visit?TreatmentDid it help?□ Anti-inflammatories□ Y □ N □ Narcotics□ Y □ N □ Physical Therapy/Home Exercise Program□ Y □ N □ Injection at last visit (short term _____days)□ Y □ N (long term _____weeks)□ Y □ N 12.Are you pregnant? □ Y □ N 13.Have you seen any other medical provider since your last visit with our office?□ Y □ N INTERVAL HISTORY: Since your last visit, have you:ROSDeveloped new problems in any of these areas? (Circle and describe) I have had no new problems in these areasAllergiesNervesLungsEyesSkinStomach Issues Other JointsDiabetesEarsPsychiatricBowel Movements# per week: 0-3 4-7 8+Circle ALL OTC laxatives you have tried: MiraLAX Senokot Dulcolax Stool Softeners Fiber EnemasWeight loss or gain FeverHeartUrineAnemiaDescribe any problems:PMHBeen prescribed new medications by any other physician?Been hospitalized for a non-orthopedic condition?□ Y □ N Describe?□ Y □ N Describe?SH Changed your smoking status?What is your current job status?□ Y □ N Describe?□ Regular job □ Light Duty □ Not working due to this condition □ Do not workFHHad any newly diagnosed medical conditions in your family?□ Y □ N Describe?Are there any questions you want the Doctor to answer for you at this visit? PLEASE LIST BELOW.________________________________________________________________________________________________________________________________________________________________________________________Please complete the following diagram and sign ???Ortho pain chartMark the areas on your body where you feel the described sensations using the appropriate symbol form the list below. Please include all affected areas.Numbness = = =Pins & Needles o o oBurning/Aching x x xStabbing / / /Patient Signature ____________________________ Provider Signature _________________ Date _________ ................
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