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Premier Pain Relief - Dr. Jeff Cullers
Clinical Interview Form
First and Last Name
Your answer
Address
Your answer
Phone number
Your answer
Email address
Your answer
Are you a resident of Volusia County Florida
What brought you here or made you call?
Your answer
How long have you had these symptoms?
Your answer
What symptoms do you have right now?
Your answer
When and how did everything start?
Your answer
Have you seen anyone especially your physician and has any diagnosis already been established? if yes - what?
Your answer
Were any tests (X-ray, MRI, CT, Nerve Conduction study) done?
Your answer
What treatments, if any, were used? If yes - what?
Your answer
Do any family members have similar problems?
Required
Were other Health Conditions or Medications eliminated by your Primary Care Physician as potential causes of your symptoms? If yes - what?
Your answer
Have you experienced previous trauma? Sport Injury, Motor Vehicle Accident Injury (Car, Truck, Motorcycle, Boat, Commercial Vehicle, ATV, etc), On the Job Injury, Slip and Fall Injury, or any other type of trauma? If yes - What was the type of trauma and when?
Your answer
How would you describe the pain you have or had? Sharp Pain if yes - where?, Aching Pain if yes - where?, Burning if yes - where? Pulsating if yes - where?
Your answer
Do you feel pain locally? If yes - where?
Your answer
Do you feel pain radiating to any neighboring parts of the body? If yes - where?
Your answer
Do you have the sensation of spreading pain? If yes - where?
Your answer
Did you notice if the pain you have is accompanied by:
Required
Did you have the sensation that the original pain triggers pain in other parts of your body? If radiating pain - where? If referred pain - where?
Your answer
Do you feel rested in the morning?
Do you feel the pain is getting worse by late afternoon/evening?
Do you have night pain?
Do you have difficulties falling asleep?
Does pain wake you up at night?
How is the pain you feel affected by your movement?
Required
How do you grade your pain intensity on a scale of 1 - 10
Minimal Pain
Severe Pain
Have you had in the past or do you currently have sensations of tingling or numbness in any parts of your body? If yes - where?
Your answer
Do you feel any restrictions in your movement (ROM) or do you feel any weakness? If yes - where?
Your answer
Do you prefer Morning, Afternoon or Evenings for Dr. Cullers to contact you? What day do you prefer?
Required
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