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4787 E Camp Lowell Dr, Tucson, AZ 85712
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2018-11-04T21:40:35-07:00
Appointment
Name
*
First
Last
Date of birth
*
MM slash DD slash YYYY
Sex
Male
Female
New or Existing Patient?
*
New Patient
Existing Patient
Who is your insurance provider?
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What is your insurance policy number?
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Do you have a referral?
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Who is your referring Dr.?
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Contact preference
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Start of appointment date range
MM slash DD slash YYYY
The first day you are available for an appointment.
End of appointment date range
MM slash DD slash YYYY
The last preferred day of appointment. (Up to one month from start date.)
How long have you had your pain?
Where do you feel the pain?
Is your pain in one spot or spread out?
How does the pain feel and how severe is it?
Is your pain constant or does it come and go?
What activities make your pain worse or improve it?
How does your pain limit what you can do?
How often and for how long does the pain occur?
Is there anything that triggers the pain?
Current Pain level
0 - No Pain
1
2 - Mild Pain
3
4 - Discomforting
5
6 - Distressing
7
8 - Intense
9
10 - Excruciating
Please check all words that describe how your pain feels.
Aching
Constant
Cramping
Fearful
Gnawing
Heavy
Hot or burning
Punishing/Cruel
Sharp
Shooting
Sickening
Splitting
Stabbing
Tender
Throbbing
Tiring or exhausting
Please check all Activities of Daily Living (ADLs) with which you are having difficulty.
Bathing
Climbing Stairs
Cooking
Doing laundry
Dressing
Driving
Eating
Grooming
Hand writing / typing
House work
Managing finances
Managing medications
Oral care
Shopping
Toileting
Transferring
Using the phone
Walking
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