Form Cms-R-131 - Application For Peripheral Neuropathy Treatment

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Application for Peripheral Neuropathy Treatment
Name:
Date:
Address:
City:
State:
Zip:_
Home Phone:
Cell Phone:
Email:
Social Security #:
-
-
Date of Birth:
/
/
Age:
Spouse’s Name:
Occupation (Current or Previous):
Retired? Y N
Insurance Provider:
Member ID:
Whom may we thank for referring you to us?
Review of Systems
Please check all that apply
□ Foot Pain
□ Diabetes
□ Spinal Stenosis
□ Cancer
□ Pinched Nerve
□ Hand Pain
□ High Cholesterol
□ Degenerative Discs □ Chemotherapy
□ Poor Circulation
□ Low Back Pain
□ High Blood Pressure
□ Vascular Problems □ Arthritis in Hands □ Joint Replacements
□ Neck Pain
□ Pacemaker/
□ Leg Pain
□ Arthritis in Feet
□ Foot Surgery
Defibrillator
□ Foot Numbness
□ Herniated Disc
□ Plantar Fasciitis
□ Implanted Cord/
□ Poor healing
Bladder Stimulator
□ RLS
□ Hand Numbness □ Bulging Disc
□ Morton’s Neuroma □ Sciatica
□ Excessive thirst or
urination
Present Health Condition
In order of importance, list the health problems you
List approximately how long you have noticed these
are most interested in getting corrected:
problems:
1)
1)
2)
2)
3)
3)
4)
4)
5)
5)
Is there a certain time of day any of these problems
List the things you have used for these problems:
are better or worse?
□Gabapentin □Neurontin □Lyrica □Cymbalta
□Physical Therapy □Pain Medications □ Aleve
□Tylenol □Ibuprofen □Motrin □Chiropractic
□Massage Therapy □Injections □Creams on Hands/Feet
Is your balance/walking ability affected? □ Y □ N
□Other Medications or Treatments:_
If yes, please describe:
1

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