Patient Intake Form

WILLIAM BLANE RICHARDSON, MD

| SOUTHERN GRACE PRECISION & AESTHETICS

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WILLIAM BLANE RICHARDSON,MD

SOUTHERN GRACE PRECISION & AESTHETICS

Patients INTAKE Form

SCHEDULE

YOUR CONSULTATION TODAY

Your Name

Phone Number

Today'sDate

Patient Address

Street

Apt/Suite/Unit

City

State

Zip Code

Date Of Birth

Age

Referring Physician

Primary Care Physician

Pain History

Chief Complaint (Reason for your visit today)?

Does this pain radiate? If so where?

Please list any additional areas of pain:

ONSET OF SYMPTOMS

Approximately, when did this pain begin?

What caused your current pain episode?

How did your current pain episode begin?

Gradually Suddenly

Since your pain began, how has it changed?

Improved Worsened Stayed the same

PAIN DESCRIPTION

Describe the character of your pain (eg: dull, stabbing, throbbing, etc):

What time of day is your pain at its worst?

How often does the pain occur?

Constant Changes in severity but always present Intermittent (comes and goes)

If pain “0” is no pain and “10” is the worst pain you can imagine, how would you rate your pain?

Right Now

The Best It Gets

The Worst It Get

What other factors worsen or affect your pain

What other factors relieve your pain?

Are there any associated symptoms? (eg: numbness/tingling/weakness/incontinence, etc)

What are the goals you wish to achieve with Pain Management?

DIAGNOSTIC TESTING & IMAGING

Mark all of the following tests that you have had related to your current pain complaints:

MRI of the

MRI Of The

Date

X-Ray of the:

Date

CT Scan of the:

Date

EMG/NCV study of the:

Date

Other Diagnostic Testing:

Date

I have not had ANY diagnostic tests for my current pain complaint

PLEASE CHECK ALL THE FOLLOWING TREATMENTS YOU HAVE HAD IN THE PAST FOR PAIN RELIEF

Pain Management Checklist

Pain	No Change	Worsened Pain	Improved
Spine Surgery
Physical Therapy
Chiropractic Care
Psychological Therapy
Brace Support
Acupuncture
Hot/Cold Packs
Massage Therapy
TENS Unit

INTERVENTIONAL PAIN TREATMENT HISTORY

Epidural Steroid Injection (Check All that apply) Cervical Thoracic Lumbar

Joint Injection – Joint(s)

Medial Branch Blocks/Facet Injections (Check All that apply) Cervical Thoracic Lumbar

Nerve Blocks – Area/Nerve(s)

Radiofrequency Nerve Ablation (Check All that apply) Cervical Thoracic Lumbar

Spinal Cord Stimulator Trial Only Permanent Implant

Trigger Point Injections – Where?

Vertebroplasty/Kyphoplasty – Level(s)

Other

Which of these procedures listed above have helped with your pain?

Please list the names of other Pain Physicians you have seen in the past?

Mark the following physicians or specialists you have consulted for your current pain problem(s):

Other Specialist

PAST MEDICAL HISTORY

Mark the following conditions/diseases that you have been treated for in the past:

ENT

Glaucoma Vertigo Hearing Problems Nosebleeds

Cancer/Oncology

Cancer - Type Cancer - Type Cancer - Type

Gastrointestinal

GERD (Acid Reflux) Stomach Ulcers Gastrointestinal Bleeding IBS/Crohns Disease

Respiratory

Asthma Bronchitis/Pneumonia Emphysema/COPD

Urological

Chronic Kidney Disease Kidney Stones Urinary Incontinence Dialysis

Endocrinology

Diabetes – Type Hyperthyroidism Hypothyroidism Adrenal Disorder

Other Diagnosed Conditions

PAST SURGICAL HISTORY

Please list any surgical procedures you have had done in the past including date

Surgical Procedure

Date

Surgical Procedure

Date

Surgical Procedure

Date

Surgical Procedure

Date

Surgical Procedure

Date

Surgical Procedure

Date

Surgical Procedure

Date

Surgical Procedure

Date

I have NEVER had any surgical procedures performed

FAMILY HISTORY

William Blane Richardson MD

SOUTHERN GRACE PRECISION & AESTHETICS

3520 PARK AVE BLVD,
STE 105, MT PLEASANT
SC 29466

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