Patient Questionnaire Page 2
Previous medication for pain:
(Name) (% Relief) (Why Stopped )
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Current medication program (list ALL medications including herbals and supplements)
(Name) (Dosage) (Schedule #daily) (% Relief) (Duration of Relief) (Date started)
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Do you have any drug allergies? Yes _____ No _____
If yes, please list _________________________________________________________________________________________
Previous surgeries for pain:
(Type) (Date) (Did it help)
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Previous treatments/therapies for pain other than surgery (i.e. acupuncture, chiropractic, physical therapy):
(Type) (Date) (Did it help)
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