Follow up visit form

FOLLOW UP QUESTIONNAIRE
Name: _______________________________________________________________Date: ________________________________ Primary Care Physician: _________________________________Referring Physician: ____________________________________ Have you changed your primary care physician?----------------------------------------------------------------------------------------YES---NO Have there been any changes to your employment/occupation?-----------------------------------------------------------------------YES---NOIf yes, please note changes:______________________________________________________________________________________________________________________________________________________________________________________________ Are you currently receiving worker’s compensation?-----------------------------------------------------------------------------------YES---NO Are you currently off work as a result of your pain?-------------------------------------------------------------------------------------YES---NO If yes, for how long? _________________________________________________________________________________________ Are you presently involved in a lawsuit regarding your pain?--------------------------------------------------------------------------YES---NO What activities are you unable to do because of your pain?_____________________________________________________________________________________________________________________________________________________________________ What activities are you now able to do after treatment (i.e., medication, injections, etc.)?____________________________________________________________________________________________________________________________________________________________________________________________________________________ Is your pain the result of a motor vehicle accident?--------------------------------------------------------------------------------------YES---NO Have there been any changes in your medical condition since your last visit?-------------------------------------------------------YES---NOIf yes, note changes:_____________________________________________________________________________________________________________________________________________________________________________________________________ Have you been to the emergency room or been hospitalized since your last visit with us?-----------------------------------------YES---NOIf yes, please explain:_____________________________________________________________________________________________________________________________________________________________________________________________________ Please list your current medications:
Drug Name
How often
Prescribing Physician
1) ________________________________________________________________________________________________________ 2) ________________________________________________________________________________________________________ 3) ________________________________________________________________________________________________________ 4) ________________________________________________________________________________________________________ 5) ________________________________________________________________________________________________________ Are you currently taking any blood thinners?--------------------------------------------------------------------------YES----NO
Please circle any that apply: Fish Oil, Cod Liver Oil, Omega 3’s, Coumadin, Warfarin, Plavix, Heparin, Ticlid,
Aggrenox, Lovenox, Pletal, Trental, Aspirin or Other: __________________________________________________
Please circle on the 0-10 scale below how severe your pain is today: (NONE) 0 1 2 3 4 5 6 7 8 9 10 (Worst Ever) How much has your pain changed since your last visit with us? Decreased Considerably Decreased Mildly Same Increased Mildly Increased Considerably Rev 06.05.08

Source: http://www.apcindy.com/downloads/APCI_Follow.up_Form__.pdf