WILLIAM BLANE RICHARDSON, MD

| SOUTHERN GRACE PRECISION & AESTHETICS

WILLIAM BLANE RICHARDSON,MD

SOUTHERN GRACE PRECISION & AESTHETICS

Patients INTAKE Form

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YOUR CONSULTATION TODAY

Patient Address


Pain History


ONSET OF SYMPTOMS

PAIN DESCRIPTION

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

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




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

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

PAST SURGICAL HISTORY

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


FAMILY HISTORY

SOCIAL HISTORY

CURRENT MEDICATIONS

Please list all medications you are currently taking including vitamins. Attach additional sheet if required:
Please list all past pain medications that you have been on at any point for your current pain complaints?
Please list all past pain medications that you have been on at any point for your current pain complaints?
REVIEW OF SYSTEMS

Mark the following symptoms that you currently suffer from:
Constitutional

Eyes

Ears/Nose/Throat/Neck

Respiratory

Cardiovascular

Gastrointestinal



Musculoskeletal

Skin

Neurological

Psychiatric

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