Neuropathy Consult Forms

Neuropathy Consultation Form

Name *

First

Last *

Last

Address

City *

State *

Zip Code *

Phone *

*We will need to contact you both by phone &email. Please be sure to provide us the best phone number to reach you.

Email *

Date of Birth *

* If you have medicare, please provide us your SSN or medicare card.

SSN Social Security

Spouse's Name

Spouse's Phone Number

Your Occupation *

Retired

Yes

Please Check all that apply

Foot Pain

Hand Pain

Lower Back Pain

Neck Pain

Foot Numbness

Hand Numbness

Diabetes

High Cholesterol

High Blood Pressure

Pacemaker/Defibrillator

Herniated Disc

Bulging Disc

Spinal Stenosis

Degenerative Disc

Vascular Problems

Leg Pain

Plantar Fasciitis

Morton's Neuroma

Cancer

Chemotherapy

Arthritis in Hands

Arthritis in Feet

Implanted Cord/Bladder Stimulator

Sciatica

Pinched Nerve

Poor Circulation

Joint Replacement

Foot Surgery

Poor Wound Healing

Excessive thirst or urination

In order of importance, list the health problems you are most interested in getting corrected: *

List approximately how long you have noticed these problems: *

List the things you have used for these problems:

Gabapentin

Neurontin

Lyrica

Cymbalta

Physical Therapy

Pain Medications

Aleve

Tynenol

Ibuprofen

Motrin

Chiropractic

Message Therapy

Injections

Creams

Is your balance/walking ability affected? If Yes, please describe:

What do you think is causing your problem?

Name of all doctors you have seen for these problems and treatment you received:

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Neuropathy Consult Form 2

Have your symptoms: *

Improved

Worsened

Stayed the same

List anything that makes your condition worse

List anything that makes your condition better

How would you describe the symptoms? Please check all that Apply *

Aching Pain

Stabbing Pain

Sharp Pain

Tiredness

Numbness

Tingling

Pins and Needles Pain

Heavy Feeling

Hot Sensation

Throbbing Pain

Dead Feeling

Cold Hands & Feet

Cramping

Swelling

Burning

Electric Shocks

Is this condition interfering with any of the following? *

Sleep

Work

Daily Activites

Recreational Activites

Walking

Standing

Do you smoke? *

Yes

If yes, how many cigarettes daily? _______________

Do you Drink? *

Yes

If yes, how many drinks per week?_____________

Do you exercise regularly? *

Yes

If yes, please describe the type & how often: _________________________

How would you rate your pain in the last week? *

No Pain

Worst Pain Possible

If you had to accept some level of pain after completion of treatment, what would be an acceptable level? *

No Pain

Worst Pain Possible

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Neuropathy Consult Form 3

Name *

Signature

Name

Phone

Address

When were you last seen there?

May we send them updates on your treatment/condition?

Yes

List ALL allergies/sensitivitiess to medication, food, and other items here:

Items you react to and their reaction.

List the prescription drugs you are currently taking

List all nutritional supplements ( vitamines, herbs,homeopathics

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Patient Quality Of Life Survey

Name *

Please take several minutes to answer these questions so we can help you get better.

Date *

How have you taken care of your health in the past? *

Medications

Emergency Room

Routine Medical

Exercise

Nutrition/Diet

Holistic Care

Vitamins

Chiropractic

Other

Other, Please Explain

How did the previous method(s) work out for you? *

Bad results

Some results

Great results

Nothing changed

Did not get worse

Did not work very long

Still trying

Confused

How have others been affected by your health condition? *

No one is affected

Haven't noticed any problem

They tell me to do something

People avoid me

What are you afraid this might be ( or beginning ) to affect ( or will affect ) ? *

Job

Kids

Future ability

Marriage

Self -esteem

Sleep

Time

Finances

Freedom

Are there health conditions you are afraid this might turn into? *

Family health problems

Heart disease

Cancer

Diabetes

Arthritis

Fibromyalgia

Depression

Chronic fatigue

Need surgery

How has your health conditionaffected your job, relationships, finances, family, or other activities? Please give examples: *

What has that cost you? ( time, money, happiness, freedom, sleep, promotion, etc. ) *

What are you most concerned with regarding your problem?

Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specific *

What would be different/better without this problem? Please be specific *

What do you desire most to get from working with us?

What would that mean to your?

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In medicine today, leaky gut aka intestinal permeability, isn’t typically diagnosed. However that doesn’t mean it’s not affecting your health. Many health issues related to gut health go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please complete this evaluation to help our doctors determine how we can help your condition.

Let’s get started
Please check any that apply to you:

Wellness Evaluation

Name *

Full name

Date *

Sub-Clinical Symptoms Including:

Headaches

Migranes

Hormone Imbalance Including:

PMS

Emotional imbalance

Gastrointestinal Issues Including:

Abdominal bloating, cramps or painful gas

Irritable Bowel Syndrome

Ulcerative Colitis

Crohn's Disease and other intestinal disorders

Respiratory Conditions Including:

Chronic sinusitis

Asthma

Allergies

Autoimmune Conditions Including:

Diabetes Mellitus

Lupus

Rheumatoid Arthritis

Fibromyalgia

Chronic Fatigue

Thyroid Conditions Including:

Hashimotos

Hypothyroidism

Hyperthyroidism

Joint Conditions Including:

Knee Shoulder, or Spine

Developmental and Social Concerns Including:

Autism

ADD/ADHD

Skin Conditions Including:

Eczema

Skin rashes

Hives

Circle the number that most closely fits, then add up your results

Constipation and / or diarrhea 0-1-2-3

Abdominal pain or bloating 0-1-2-3

Mucous or blood in stool 0-1-2-3

Joint pain or swelling, arthritis 0-1-2-3

Chronic or frequent fatigue or intolerance 0-1-2-3

Sinus or nasal congestion 0-1-2-3

Chronic or frequent inflammation 0-1-2-3

Eczema, skin rashes or hives ( urticaria) 0-1-2-3

Circle the number that most closely fits, then add up your results

Asthma,Hayfever, or airborne allergies 0-1-2-3

Confusion, poor memory or mood swings 0-1-2-3

use of NSAIDS ( Asprin, Tynenol, Motrin) 0-1-2-3

History of antibiotics use 0-1-2-3

Alcohol consumption makes you feel sick 0-1-2-3

Gluten sensitivity or Celiac's disease

Nausea 0-1-2-3

Weight Issues -01-2-3

Enter your total for the above conditions

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