INTERNATIONAL HOUSE OF PAIN CLINIC INITIAL VISIT www.internationalhouseofpain.com
Please completely fill out the form below. The more complete you are, the better i can care for you. for you!
This is a problem sheet. Please use this sheet to describe ONE pain you are having. The more complete you are the more likely it is we can diagnose and treat you. If you have more than one painful problem please use an additional problem sheet.
Please indicate the location of your symptoms using the following symbols:
*
Required
NAME: *
Your answer
DATE: *
MM
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DD
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YYYY
WHEN DID THE PAIN START?: VAS: Please circle/rate your AVERAGE PAIN LEVEL OVER THE PAST WEEK *
0-10 scale with 0=No Pain and 10=The Most Pain Imaginable
Pain is: Improving or Worsening or Stable / Constant or Intermittent
Pain is due to: *
Required
What increases pain?: *
Required
What reduces pain?: Please describe the history of this pain: *
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