Questions About Your Condition |
| What is your main problem/symptom(s) prompting your request for a consultation with the Doctor today? |
| Would you consider this problem? |
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| In spite of the fact that you are not a specialist, and you are in fact the person who knows more about your pain than anyone else. In your own words and in your own opinion what do you think the real problem is? |
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| What kinds of treatments have you tried previous to today? |
| Epidural: |
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| How Many: |
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| When (approx): |
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| Physical Therapy: |
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| How Long: |
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| When (approx): |
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| Medication(s): |
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| When (approx): |
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| Surgery: |
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| Type: |
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| When (approx): |
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| Other: |
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| Did any of these treatments work? If so which one(s) and for how long? |
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| What do you do on your own to alleviate the condition/pain? |
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| What activities/movements are guaranteed to make the condition/pain worse? |
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Please describe the quality of the pain:
(sharp, dull, achy, “toothache”, shooting, stabbing, numb, tingling, etc...) |
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When is the pain at its worst?
(Example: in the morning, as the day progresses, etc) |
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| When is the VERY FIRST time you recall having this problem? |
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| If you cannot find a solution to this problem what do you think will happen to you? |
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| In Reference to your MAIN PROBLEM how often are you aware of This Problem? |
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