Pain Brace Intake Form
ALL OF THE PATIENT INFO SHOULD BE COPIED AND THEN PASTED FROM CORTEX!!
Patient First Name *
Your answer
Patient Last name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Member ID Number *
Your answer
State *
Your answer
Shipping Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Secondary Phone Number *
Your answer
Braces Requested *
Check all that apply.
Required
What Caused this pain? *
Pain Level at its very worst *
When did the pain begin? *
Estimated date
MM
/
DD
/
YYYY
Have you had surgery for this?? *
What other treatments have you tried? *
Required
Current Pain Medications *
Your answer
How often do you feel pain? *
What Makes Pain worse? *
Last time you saw primary about pain? *
MM
/
DD
/
YYYY
Are you a diabetic? *
(If Diabetic) Are you insulin dependent ? *
Do you have a fear of falling? *
Medication Allergies *
Your answer
Height *
Your answer
Weight *
Your answer
Lumbar (Back) brace Size *
What is your shoe size? *
Your answer
Agent Name? *
Your answer
If Patient is diabetic, would they like a follow up call about discounted diabetic supplies like testing strips and meters? *
Notes:
Your answer
Did you complete compliance recording? *
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