Return office visit questionnaire.xls

Michigan Pain Specialists
(734) 995-72463520 Green Court, Suite 100Ann Arbor, MI 48105 Office Visit Questionnaire
Date:Please fill out all pages completely. This occurs at each visit. Thank you. Please show the location of your pain by drawing on the figures below:
Has your pain improved since your last visit? Yes / No If yes, how long did your pain improve?
What was the maximum percent improvement? What activities are you able to do as a result of your treatments? Have you had any side effects from the treament(s)? Do you have any fever, chills, or active infections? Michigan Pain Specialists
(734) 995-72463520 Green Court, Suite 100Ann Arbor, MI 48105 Office Visit Questionnaire
Please fill out all pages completely. This occurs at each visit. Thank you. Please mark where you are on the following scales (on average):
Have you had any of the following problems? Please circle Yes or No.
Do you use alcohol with opioid medicines Do you take any of the following medications?
List ALL drugs that have CHANGED since your last visit:
List all Allergies:
Have you had any tests done since your last visit (x-rays, MRI, blood tests)?
Please list:
Please circle all medical conditions that affect you:
Treating physician:
Fever, unintentional weight loss, HIV, Cancer Type___________________________ Cold symptoms, sinusitis, sore throat, hearing loss Glaucoma, cataracts, macular degeneration, blindness Heart attack, heart failure, irregular rhythm, palpitations, chest pain, poor circulation, valve disease, high blood pressure Cough, Asthma, COPD, Emphysema, Chronic Bronchitis, shortness of breath, Home oxygen use Nausea/ vomiting, diarrhea, ulcers, constipation, reflux, liver cirrhosis, hepatitis, loss of bowel control Renal failure, UTI, kidney stones, blood in urine, loss of bladder control, impotence Diabetes, thyroid disease, calcium imbalance Enlarged lymph nodes in neck, arm pits, or groin areas Michigan Pain Specialists
(734) 995-72463520 Green Court, Suite 100Ann Arbor, MI 48105 Office Visit Questionnaire
Date:Please fill out all pages completely. This occurs at each visit. Thank you. Arthritis, osteoporosis, lupus, rheumatoid arthritis, spinal stenosis, disc disease, neck pain, back pain, sciatica, radiculopathy Rash, infection, blisters, psoriasis, dermatitis, eczema, Any skin infections or ulcers now or in the past Stroke, seizures, paralysis, TIA, mini-strokes, facial drooping, slurred speech, neuropathy Bleeding history, blood clots, Von Willebrand’s Disease, Sickle Cell Anemia, Hemophilia, excessive bleeding when cut, easy bruising Insomnia, excessive tiredness, anxiety, depression Are you, or could you, be pregnant?
All other systems negative except those noted above.
MRI films available and reviewed.
MRI report available and reviewed.
I have personally reviewed this entire document.

Source: http://www.michiganpainspecialists.com/forms/office_visit.pdf