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)
__________________________________________________ _____________________ ______________________
Previous treatments/therapies for pain other than surgery (i.e. acupuncture, chiropractic, physical therapy):
(Type)
(Date) (Did it help)
__________________________________________________ _____________________ ______________________