DRX 9000 Registration Form
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- James Isaac Walters
- 8 years ago
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1 DRX 9000 Registratin Frm Yu have been qualified fr a cnsultatin with the dctr. This hwever des NOT mean that yur case has been accepted. Yur cnsultatin tday will determine if: A) Yu are a legitimate candidate fr this prgram B) Yur cnditin is serius enugh t warrant yur case being accepted fr this treatment Name: Age: Birthday: (MMDDYYYY) Sex: Address: Hme Phne: ( ) Wrk Phne: ( ) Best place t reach yu: Cellular Phne: ( ) Hme Wrk Cellular May we leave a vice mail message fr yu? Yes N Emplyer: Occupatin: Marital Status: Single Married Divrced Widwed Spuse s Name: Yur SIN#: I cnsent t allw the dctr t speak with me and perfrm an examinatin (if necessary) in rder t determine if I am a gd candidate fr nn-surgical spinal decmpressin and als t determine if he is willing t accept my case. Signature: Hw did yu hear abut Spinal Decmpressin? Hw serius d yu think yur prblem is? (Scale = feeling gd. 10= extremely bad) What is yur main prblem/symptm prmpting yur request fr a cnsultatin with the dctr? Back Neck Other Wuld yu cnsider this prblem: MINIMAL (annying but causing NO limitatins) SLIGHT (tlerable but causing little limitatin) MODERATE (smetimes tlerable but definitely causing limitatins) SEVERE (causing significant limitatins) EXTREME (causing near cnstant [>80% f the time] limitatins) 1
2 In spite f the fact that yu are nt a back specialist, yu are in fact the persn wh knws mre abut yur back than anyne else. In yur wn wrds and in yur wn pinin, what d yu think the real prblem is? What are yu hping happens tday as a result f yur cnsultatin with the dctr? Since yur back pain became this sever what three things has it caused yu t miss the mst? Hw lng have yu been like this fr? Hw has yur life changed since yur back and/r neck became a prblem? What activities are yu limited in? What kinds f treatments have yu received? Epidural: Hw Many When (apprx) Physical Therapy: Hw Lng When (apprx) Medicatin: Type When (apprx) Surgery: Type When (apprx) Other: In general, when did yu received these treatments and fr hw lng? Did any f these treatments wrk? If s, which ne(s)? Fr hw lng? Is there anything that yu can d that makes it feel better? What activities/mvements are guaranteed t make it wrse? Please describe the quality f the pain. (sharp, dull, achy, tthache, shting, stabbing, numb, tingling, etc ) Is it wrst in the mrning r is it wrse as the day prgresses? 2
3 If yu cannt find a slutin t this prblem, what d yu think will happen t yu? What are yu hping the dctr tells yu tday? Describe what yu hpe r thing he might be able t d fr yu? Describe what will be different in yur life if yu can get better? When is the VERY FIRST time yu recall having this prblem? In reference t yur main prblem, hw ften are yu aware f this prblem? Occasinally (25% f the time) Intermittently (50% f the time) Frequently (75% f the time) Cnstant (90-100% f the time) Due t yur main prblem Have yu lst any time frm wrk? Yes N Hw much time and what tasks have been limited? Have yu lst any time frm yur chres/tasks at hme? Yes N Hw much time and what tasks have been limited? Have yu lst any time frm yur family? Yes N Hw much time and what tasks have been limited? Have yu lst any time frm yu leisure activities? (hbbies, travel, sprts, etc.) Yes N Hw much time and what tasks have been limited? Cnsidering the amunt f pain/discmfrt yu ve had THIS week, hw lng has yur prblem been this severe? On a scale f 0-10 (10 bring unbearable, 0 being n pain r discmfrt) please rate the fllwing The HIGHEST yur pain gets WITHOUT medicatin The LOWEST yur pain gets WITHOUT medicatin The HIGHEST yur pain gets WITH medicatin The LOWEST yur pain gets WITH medicatin List any surgeries that yu have had and the crrespnding dates. 3
4 Have yu had ANY f the fllwing in the last 12 mnths r currently? Please mark C fr current, X fr last 12 mnths. GENERAL Chills Cnvulsins Dizziness Fainting Fatigue Fever Headache Lss f sleep Numbness in BOTH hands & feet Lss f weight Nervusness Wheezing Brnchitis Allergy [t what ] CARDIOVASCULAR High bld pressure Lw bld pressure Pain ver heart Pr circulatin Rapid heartbeat Slw heartbeat Previus heart prblem [please describe: ] Strke TIA Swllen ankles Varicse veins Artic aneurysm Bruise easily DISEASES/CONDITIONS Appendicitis Diabetes Kidney disease Anaemia Depressin Liver disease Arthritis Epilepsy Lw back pain Alchlism Eczema Mental illness Abdminal surgery Eating disrder Measles Bleeding disrder Glaucma Pneumnia Bld clt(s) HIV+ Hyperthyrid Breathing difficulty Heart disease Hypthyrid Cancer Hernia Rectal surgery Chlesterl high Headaches Cln prblems Influenza 4
![pressure Lw bld pressure Pain ver heart Pr circulatin Rapid heartbeat Slw heartbeat Previus heart prblem [please describe: ] Strke TIA Swllen ankles Varicse veins Artic aneurysm Bruise easily](/docs-images/53/11142323/images/page_4.jpg "DISEASES/CONDITIONS Appendicitis Diabetes Kidney disease Anaemia Depressin Liver disease Arthritis Epilepsy Lw back pain Alchlism Eczema Mental illness Abdminal surgery Eating disrder Measles")
5 EARS/ EYES/ NOSE/ THROAT Asthma Difficulty swallwing Thyrid prblem Crssed eyes Deafness Nse bleeds Duble visin Hearing lss Sinus prblems Blurred visin Ear pain Sre thrats GASTRO-INTESTINAL Gas Haemrrhids Pr digestin Cln truble Liver truble Vmiting Cnstipatin Nausea Vmiting bld Diarrhea Stmach ache Rectal bleeding Gallbladder truble Pr appetite Blating FOR WOMEN ONLY Menstrual cramps Excessive menstrual flw Ht flashes Irregular cycle Painful perids Birth cntrl pills Abnrmal pap smear GENITO-URINARY Bld in urine Frequent urinatin Inability t cntrl urine Kidney infectin Painful urinatin Prstate truble FOR MEN ONLY Lump in testicles Penis discharge MUSCLE/ JOINT/ BONE Backache Ft truble Bain between shulders Painful tailbne Stiff neck Spinal curvature Swllen jints 5
6 NEUROLOGIC Seizures Dizziness Hand trembling Weakness Difficulty with speech Lss f memry Lss f crdinatin RESPIRATORY Chest pain Chrnic cugh Difficulty breathing Cughing/spitting bld 6
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