Western Reserve Hospital Pain Management

New Patient Questionnaire

 
 
Phone
 
 
 
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Specific location of pain

 
 
mm/dd/yyyy
 
 
 

Please be specific.

 
 
 

Past Medical History

 
 
 

Previous Evaluation and Treatment for your Current Problem

 
 

Have you had any of these tests completed for this condition?

 
 
 
 
 
 
 

Have you had any of the following treatements for this condition? If YES, please indicate the effectiveness of the treatmenet received.

 
 
 
 
 
 
 
 
 
 
 
 
 
 

Medications

List all of your current medications, dosage and how many times per day you take them. Include ALL prescribed, over-the-counter, vitamins and herbal medications, supplements.

 

Name, Dosage, How often per day

 

Name, Dosage, How often per day

 

Name, Dosage, How often per day

 

Name, Dosage, How often per day

 

Name, Dosage, How often per day

 

Name, Dosage, How often per day

 

Name, Dosage, How often per day

 

Name, Dosage, How often per day

 

Name, Dosage, How often per day

 

Name, Dosage, How often per day

 

This questionnaire will become part of medical record. Any false information or omissions may lead to termination of treatment by Western Reserve Hospital. Complications and side effects due to falsifications or omissions are the responsibility of the patient.

 
 
 
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