Neuropathy Consult Form

Neuropathy Intake Form


Please fill out the application entirely and legibly. We need all information for insurance purposes.

*We will need to contact you both by phone & email. Please be sure to give us the best phone number to reach you*

*If you have Medicare, we need you to list your SSN above or provide us with the Medicare card*

Retired

REVIEW OF SYMPTOMS


Please check all that apply

PRESENT HEALTH CONDITION


In order of importance, list the health problems you are most interested in getting corrected:

List approximately how long you have noticed these problems:

List the things you have used for these problems:
Have your symptoms:
How would you describe the symptoms? Please check ALL that apply
Is This Condition Interfering With Any of the Following?

SOCIAL HISTORY


Do you smoke?
Do you drink?
Do you exercise regularly?

CURRENT PAIN LEVELS


How would you rate your pain in the last week?
If you had to accept some level of pain after completion of treatment, what would be an acceptable level?

PREVIOUS HEALTH HISTORY HEALTH


This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization, unless you sign here indicating that we can release copies by your verbal request.

Please give name, address, and office phone number of your primary care physician.

May we send them updates on your treatment/condition?

List ALL allergies/sensitivities to medication, food, and other items here:

List the prescription drugs you are currently taking (or you may attach a list):

List all nutritional supplements (vitamins, herbs, homeopathic's, etc.) as above:

Patient Quality Of Life Survey

Please take several minutes to answer these questions so we can help you get better.

(Please mark as many that apply)

1. How have you taken care of your health in the past?
2. How did the previous method(s) work out for you?
3. How have others been affected by your health condition?
4. What are you afraid this might be (or beginning) to affect (or will affect)?
5. Are there health conditions you are afraid this might turn into?

Thank you for taking the time to fill out this form.

Our Location

Hours of Operation

Monday

10:00 am - 7:00 pm

Tuesday

10:00 am - 7:00 pm

Wednesday

8:30 am - 1:00 pm

Thursday

8:30 am - 1:00 pm

Friday

8:30 am - 1:30 pm

Saturday

Closed

Sunday

Closed

Monday
10:00 am - 7:00 pm
Tuesday
10:00 am - 7:00 pm
Wednesday
8:30 am - 1:00 pm
Thursday
8:30 am - 1:00 pm
Friday
8:30 am - 1:30 pm
Saturday
Closed
Sunday
Closed