Application For Neuropathy Treatment Form
ADVERTISEMENT
1
2
3Application for Neuropathy Treatment
Name:__________________________________________
Date:__________________________
Address:____________________________________________________________________________________________
City:______________________ State:_____ Zip:_________________ Home Phone:_____________________________
Work Phone:_______________________ Cell Phone:______________________
Social Security #:_____-____-______ Date of Birth:____/____/____ Age:_____
Spouse’s Name:______________________________________________________________________________________
Occupation (Current or Previous):________________________________________________________Retired: Y N
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 wound heal-
Bladder Stimulator
ing
□ 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 □ Alleve
_________________________________________________
□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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business