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WILLIAM BLANE RICHARDSON, MD
| SOUTHERN GRACE PRECISION & AESTHETICS
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OUR OFFICE
William Blane Richardson, MD
Abrah Gruber, RN
Jennifer Shand, PM
First Visit
3D Camera Technology
Testimonials
FAQs
PROCEDURES
Face
Acne Treatments with Aviclear
Dermal Fillers
Wrinkle Reducers
Botox
Jeuveau
Xeomin
RF Microneedling with VIRTUE
Skinwave Facial Treatment
Body
Alma TED Hair Restoration
Laser Hair Removal
EmSculpt Neo
Fat Transfer with Alma BeautiFill
Emsella
IV Therapy
Ozempic
Skin
Hyperpigmentation Reduction
Motus AY
Photorejuvenation
Vascular Lesion Reduction
GALLERY
Acne Treatments with Aviclear
Alma TED Hair Restoration
Botox
Fat Transfer with Alma BeautiFill
Hyperpigmentation reduction
Jeuveau
Photorejuvenation
RF Microneedling with VIRTUE
Vascular Lesion Reduction
Xeomin
MEMBERSHIP
Tiers & Benefits
PRODUCTS
Alumier MD
Bright & Clear Solutions
Acne Clarifying Cleanser
Calm-R
Acne Balancing Serum
HydraDew
Retinol Resurfacing Serum
Sheer Hydration Broad Specturm SPF 40
Clear Shield Broad Spectrum SPF 42
SkinCeuticals
C E Feruile
Phloretin CF
Triple Lipid Restore 2:4:2
A.G.E. Interrupter
Retinol 0.5
Belmish + Age Defense
BlaneMed
Precision DIM
Precision Magnesium
Precision B-Complex
Precision ADK+
Precision Omegas
MEDIA
Article and Gallery
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CONTACT US
ACCOUNT
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HOME
OUR OFFICE
William Blane Richardson, MD
Abrah Gruber, RN
Jennifer Shand, PM
First Visit
3D Camera Technology
Testimonials
FAQs
PROCEDURES
Face
Acne Treatments with Aviclear
Dermal Fillers
Wrinkle Reducers
Botox
Jeuveau
Xeomin
RF Microneedling with VIRTUE
Skinwave Facial Treatment
Body
Alma TED Hair Restoration
Laser Hair Removal
EmSculpt Neo
Fat Transfer with Alma BeautiFill
Emsella
IV Therapy
Ozempic
Skin
Hyperpigmentation Reduction
Motus AY
Photorejuvenation
Vascular Lesion Reduction
GALLERY
Acne Treatments with Aviclear
Alma TED Hair Restoration
Botox
Fat Transfer with Alma BeautiFill
Hyperpigmentation reduction
Jeuveau
Photorejuvenation
RF Microneedling with VIRTUE
Vascular Lesion Reduction
Xeomin
MEMBERSHIP
Tiers & Benefits
PRODUCTS
Alumier MD
Bright & Clear Solutions
Acne Clarifying Cleanser
Calm-R
Acne Balancing Serum
HydraDew
Retinol Resurfacing Serum
Sheer Hydration Broad Specturm SPF 40
Clear Shield Broad Spectrum SPF 42
SkinCeuticals
C E Feruile
Phloretin CF
Triple Lipid Restore 2:4:2
A.G.E. Interrupter
Retinol 0.5
Belmish + Age Defense
BlaneMed
Precision DIM
Precision Magnesium
Precision B-Complex
Precision ADK+
Precision Omegas
MEDIA
Article and Gallery
RESOURCES
Cherry
Out of Town
Payment and Finances
Patients Resources Form
MEMBERS
CONTACT US
ACCOUNT
Login
Signup
Forgot Password
X
CONTACT US
WILLIAM BLANE RICHARDSON,MD
SOUTHERN GRACE PRECISION & AESTHETICS
Patients INTAKE Form
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YOUR CONSULTATION TODAY
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Patient Intake Form
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:
X-Ray of the:
Date
CT Scan of the:
CT Scan of the:
Date
EMG/NCV study of the:
EMG/NCV study of the:
Date
Other Diagnostic Testing:
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):
Acupuncturist
Chiropractor
Internist
Physical Therapist
Neurosurgeon
Orthopedic Surgeon
Psychiatrist/Psychologist
Rheumatologist
Neurologist
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
Cardiovascular/Hematologic
Anemia
Heart Attack
Coronary Artery Disease
Stoke/TIA
High Blood Pressure
Peripheral Vascular Disease
Heart Valve Disorders
Presence of stent/pacemaker/ defibrillator
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
Neurological
Multiple Sclerosis
Peripheral Neuropathy
Seizures
Balance Disorder
Head Injury
Headaches
Migraines
Musculoskeletal/Rheumatologic
Bursitis
Carpal Tunnel Syndrome
Fibromyalgia
Osteoarthritis
Osteoporosis
Rheumatoid Arthritis
Chronic Joint Pains
Psychological
Depression
Anxiety
Schizophrenia
Bipolar Disorder
ADD/ADHD
PTSD
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
Arthritis
Cancer
Diabetes
Kidney Problems
Headaches/Migraines
High Blood Pressure
Stroke
SeizuresLiver Problems
Rheumatoid arthritis
Osteoporosis
Other Medical Problems
I have no significant family medical history
SOCIAL HISTORY
Occupation
When was the last time you worked?
Who is in your current household?
Are there any stairs in your current home?
If so how many?
Temporary Disability
Permanent Disability
Retired
Unemployed
Are you currently under worker’s compensation?
Yes
No
Is there an ongoing lawsuit related to your visit today?
Yes
No
Alcohol Use:
Social Use
Daily use of alcohol
Never
History of alcoholism
Current alcoholism
Tobacco Use
Tobacco Use
Former user
Never used
Packs per day?
How many years?
Quit Date:
Illegal Drug Use
Denies any illegal drug use
Currently uses illegal drugs
Have you ever abused narcotic or prescription medications?
Yes
No
CURRENT MEDICATIONS
Are you currently taking any blood thinners or anti-coagulants?
Yes
No
If YES, which ones?
Aspirin
Plavix
Coumadin
Lovenox
Other
Please list all medications you are currently taking including vitamins. Attach additional sheet if required:
Medication Name
Dose
Medication Name
Dose
Medication Name
Dose
Medication Name
Dose
Medication Name
Dose
Medication Name
Dose
Medication Name
Dose
Medication Name
Dose
Please list all past pain medications that you have been on at any point for your current pain complaints?
Medication Name
Dose
Medication Name
Dose
Medication Name
Dose
Medication Name
Dose
Medication Name
Dose
On average, how often do you have a bowel movement? (Please check one)
More than 3 times per day
2 to 3 times per day
Once per day
2 to 3 times per week
Less than once per week
When you started pain medicine, did your bowel habits change? If so how
Please list all past pain medications that you have been on at any point for your current pain complaints?
Medication Name
Allergic Reaction
Medication Name
Allergic Reaction
Medication Name
Allergic Reaction
Medication Name
Allergic Reaction
Medication Name
Allergic Reaction
Topical Allergies:
Latex
Iodine
Tape
IV Contrast
I have no known drug allergies
REVIEW OF SYSTEMS
Mark the following symptoms that you currently suffer from:
Constitutional
Fevers
Chills
Sweats
Weakness
Fatigue
Decreased Activity
Malaise
Unexplained weight gain
Unexplained weight loss
Difficulty sleeping
Low sex drive
Eyes
Blurriness
Double vision
Visual disturbance
Pain
Ears/Nose/Throat/Neck
Hearing problems
Ear pain
Sinus problems
Sore throat
Nose bleeds
Respiratory
Shortness of breath
Cough
Sputum production
Wheezing
Cardiovascular
Chest pain
Palpitations
Swelling in feet
Shortness of breath during sleep
Blood clots
Fainting
Gastrointestinal
Painful urination
Blood in urine
Change in urine stream
Unusual discharge
Flank pain
Urinary incontinence
Musculoskeletal
Back pain
Neck pain
Joint pain
Muscle pain
Muscle cramp
Trauma
Gait disturbances
Joint stiffness
Joint swelling
Muscle spasm
Skin
Rash
Itching
Lesions
Bruising
Neurological
Abnormal balance
Confusion
Numbness
Tingling
Dizziness
Headaches
Memory loss
Seizures
Tinnitus
Tremors
Vertigo
Psychiatric
Feeling anxious
Depressed mood
Suicidal thoughts
Hallucinations
Stress problems
Suicidal planning
Thoughts of harming others
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