Treatment History. Document the history of all treatment past and present:
Treatment History. List below all professional and/or personal efforts that have been made to address your son/daughter’s emotional, behavioral, or substance abuse problems (i.e., therapy, hospitalizations, treatment programs, placement, etc.). List the most current treatment first; include addresses and telephone numbers. Add additional sheets if needed. Intervention 1: Reason: Professional/Therapist: Credentials: Address: Telephone: ( ) Your assessment of treatment outcome: Intervention 2: Reason: Professional/Therapist: _ Credentials: Address: Telephone: ( ) Your assessment of treatment outcome: Intervention 3: Reason: Professional/Therapist: Credentials: Address: Telephone: ( ) Your assessment of treatment outcome: Intervention 4: Reason: Professional/Therapist: Credentials: Address: Telephone: ( ) Your assessment of treatment outcome: _ Name of Person completing this form (Printed Name): Signature of person completing this form: MEDICAL HISTORY Participant’s name: Person completing form and relation:
Treatment History. If you do not have back or low back pain, skip this section and go to “past medical history” section) Which of the following caregivers have you visited prior to your arrival here? (Please provide names) □ Family Physicians (includes general practitioners, Internists, gynecologists, etc.) □ Orthopedic Surgeon □ Neurologist □ Rheumatologist □ Chiropractor □ Acupuncturist □ Physical Therapy □ Other Pain Management Which of the following test(s) have you undergone prior to your arrival today? □ X-Rays □ CAT Scan □ MRI Scan □ EMG test □ Discogram □ Neural Block □ Myelogram Have you had any of the following interventions done for your neck or low back pain? □ Trigger Point Injections □ Ultrasound □ Heat □ Cold □ Cryotherapy □ TENS/ nerve stimulator □ Discography □ Facet □ Sacroiliac □ Other Joint injections Have you ever had any of the following surgical interventions (for neck and back pain)? □ Back Surgery: fusion Date: _ □ Back Surgery: non-fusion Date: _ □ Back Surgery: Spinal Cord Stimulator Date: _ List all Surgeries and their DATES: PATIENT HISTORY Please list all, if any DRUG ALLERGIES and their REACTIONS: Do you take any of the following? □ Aspirin □ Coumadin □ Plavix □ Heparin □ Pletal □ Lovenox □ Ticlid □ Effient Please list all MEDICATIONS CURRENT MEDICATIONS DOSAGE HOW OFTEN
