| What is your name?: |
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| What is your email address?: |
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| What is your phone number?: |
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| What is your fax number?: |
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| Do you have any current or history of intracranial pathology?: |
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| Have you ever been treated for a psychiatric condition? What was the diagnosis?: |
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| Do you have a history of headaches? What cause? How treated?: |
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| Do you have any history of seizures? Treatment?: |
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| Do you have high blood pressure? Are you taking medication? Does this medication control your pressure?: |
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| Please provide the name, address, and contact number for your primary physician.: |
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| Please provide the name, address, and contact number of your pain specialist.: |
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| Who diagnosed you with RSD/CRPS, Fibromyalgia, or Lyme Disease?: |
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| How long have you had your pain condition?: |
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| What was the initial cause?: |
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| How has it changed or progressed?: |
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| How do you experience it?: |
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| What parts of your body are affected?: |
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| What medications have you used to control it?: |
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| How well do the medications control the pain?: |
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| Have you had any interventional treatments such as blocks or injections?: |
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| What were the results of these treatments?: |
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| Do you have any current unresolved issues or diagnoses that trigger your pain?: |
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| Have you ever been told that part of your pain is "narcotic induced hyperalgesia"?: |
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| Are you currently physically dependent on narcotics? If ketamine is successful, will you require help with narcotic withdrawal?: |
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| Please describe your associated symptoms, eg: swelling, skin color or temperature change, reaction to light touch or pressure, sweating or dryness of skin, etc.: |
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| What is your age? Gender? Height? Weight?: |
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| Please list your past medical history: |
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| Please list your past surgical history: |
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| Do you have any allergies to medications? What reaction do you experience (be very specific)?: |
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| Please provide a complete list of your current medications including name of medication, dose, frequency, condition used for: |
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| How many treatments are you requesting?: |
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| What dates would you prefer to recieve treatment?: |
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