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Patient Forms

Patient Forms

Welcome!
Please take a moment and fill out the patient form below.

Name

Date of Birth

Height

Weight (lbs)

Has your medical coverage changed from your last visit?

Yes No

Reason for today's vist (Check all that apply)?

Medication Refill Medication Change Review MRI Results Post-Procedure Assessment Review Test Results

Pain Description - On a scale of 1 to 10, with 10 being the most pain, where would you rate your pain right now?

1 2 3 4 5 6 7 8 9 10

Using the same scale, please rate your worst pain you've ever felt:

1 2 3 4 5 6 7 8 9 10

Again, using the same scale, please rate your least pain you've ever felt:

1 2 3 4 5 6 7 8 9 10

Your average pain over the last month:

1 2 3 4 5 6 7 8 9 10

Where is your worst area of pain?

Does this pain radiate? If so, where?

Select all that describe your pain today:

Aching Cramping Dull Tingling/Pins & Needles Hot/Burning Numb Shock-like Shooting Spasming Squeezing Tiring/Exhausting Stabbing/Sharp Throbbing

Which word best describes the frequency of your pain?

Constant Intermittent

When is your pain at its worst?

Mornings During the day Evenings Middle of the night

In the past 30 days, how often have you had to go to someone other than your prescribing physician to get sufficient pain relief from your medications? (i.e., another doctor, the emergency room)

In the past 30 days, how often have you needed to take pain medications belonging to someone else?

In the past 30 days, how much of your time was spent thinking about opioid medications (having enough, taking them, dosing schedule, etc.)?

Not at all A little More than half the days Every Day

In the past 30 days, how often have you had to take more of your medication than prescribed?

Not at all A little More than half the days Every Day

In the past 30 days, how often have you used your pain medicine for symptoms other than for pain (e.g., to help you sleep, improve your mood, or relieve stress)?

Not at all A little More than half the days Every Day

In the past 30 days, how often have you had to visit the emergency room?

Constitutional:

Chills Difficulty Breathing Easy Bruising Excessive Sweating Excessive Thirst Fatigue Fevers Insomnia Low Sex Drive Night Sweats Tremors Unexplained Weight Gain Unexplained Weight Loss

Eyes:

Recent Visual Changes

Cardio Vascular:

Bleeding Disorder Chest Pain Hearing Problems Nosebleeds High Blood Pressure Irregular Heart Beat Lightheadedness Swelling in the Feet Shortness of Breath During Sleep

Respiratory:

Cough Wheezing Pulmonary Embolism Shortness of Breath on Exertion/Effort

Gastrointestinal:

Abdominal Cramps Acid Reflux Constipation Dark and Tarry Stools Diarrhea Hernia Vomiting Coffee Ground Appearance in Vomit

Musculoskeletal:

Back Pain Joint Pain Joint Stiffness Joint Swelling Muscle Spasms Neck Pain

Genitourinary/Nephrology:

Blood in Urine Flank Pain Painful Urination Decreased Urine Flow/Frequency/Volume

Neurological:

Dizziness Headaches Numbness/Tingling Carpal Tunnel Syndrome Tremors Seizures Instability When Walking

Psychiatric:

Depressed Mood Feeling Anxious Stress Problems Suicidal Thoughts Suicidal Planning

In the past 30 days, how often have you had trouble with thinking clearly or had memory problems?

In the past 30 days, how often have you seriously thought about hurting yourself?

Not At All Less Than Half More Than Half Every Day

In the past 30 days, how often have you gotten angry with people?

Not At All Less Than Half More Than Half Every Day

Please let us know how you feel after your most recent procedure:

Please briefly describe the type of pain you are experiencing and its location:

9370 SW Greenburg Rd,

Washington Building #602,

Tigard, OR 97223

503-238-7246

Copyright 2019 Balog Regenerative. All Rights Reserved.

Disclaimer

This form is directly linked to your prescriptions. Please fill out these forms the day of your appointment, during business hours.

Any form filled out after hours will be processed the next working business day.

This form is to be filled out for each visit.

Thank you.