Microsoft word - fu form 09.doc

Describe any symptom changes since your last visit.
If you have had an injection since your last visit,
how would you rate your satisfaction (circle one)?
1. Not at all satisfied
satisfied
3. Neither satisfied nor dissatisfied
4. Mostly satisfied
symptoms:
satisfied
Are you in Physical Therapy? Yes
If yes, date of last visit?
Since your last visit, are you:
Better by _____%
Are you doing a home exercise program?
If yes, how often?

Circle the number that best describes your current
pain with “10” being the most severe.
NECK/ARM
0 1 2 3 4 5 6 7 8 9 10
appropriate symbols. These symbols describe what
BACK/LEG
0 1 2 3 4 5 6 7 8 9 10
you feel.
Numbness Pins & Needles Burning Stabbing/Sharp Aching
How long/far can you:
o o o . . . . X X X ! ! ! - - - -

If you are taking medications, please list (include
dosage):


Have you had any medical testing since your last visit?
No _____
Yes _____ (Please list)

Have you seen any other physicians since you last visit?
No _____
Yes _____

(If yes, who and for what reason?)


Are you currently working? Yes
Any work restrictions?
Send Form
[] Flexeril 5/10 mg 1 p.o. q. 8 hr p.r.n. [] Valium 2/5/10 mg 1 p.o. 1 hr prior to procedure [] Naprosyn 375/500 mg 1 p.o. b.i.d with food [] Senokot-S 1-2 p.o. b.i.d.-t.i.d. p.r.n. [] Neurontin 100/300/400/600/800 mg max 3600 mg/day [] Midrin 1 p.o. q 1 h prn (start 1-2, Max 5/12h) [] Fioricet 1-2 p.o q 4 h prn (Max 6/24h) [] Trileptal 150/300/600 mg max 2400 mg/day [] Maxalt 5/10 mg 1 p.o. q 2 h prn (Max 30mg/24h) [] Lyrica 50/75/100/150 mg max 300 mg/day [] Relpax 20/40 mg 1 p.o. q 2 h prn (Max 80mg/24h) [] Tylenol #3 1 p.o. q. 8 hr p.r.n. pain [] Darvocet N-100 1 p.o. q. 8 hr p.r.n. pain ANTIDEPRESSANTS [] Vicodin 5/7.5/10 mg 1 p.o. q. 8 hr p.r.n. pain [] Ambien or Sonata 5/10 mg 1 p.o. q. h.s. [] Ultracet 37.5 mg 1 p.o. q. 8 hr p.r.n. pain [] Trazadone 50/100/150/300 mg 1p.o. q.h.s. max 400mg [] Percocet 2.5/5.0/7.5/10 mg 1 p.o. q. 8 hr p.r.n. pain [] Pamelor 10/25/50/75 mg 1 p.o. q. h.s. [] MS Contin 15/30/60/100 mg 1 p.o. q. 12 hr [] Elavil 10/25/50/75/100/150 mg 1 p.o. q. h.s. [] MS IR 15/30 mg 1-2 p.o. q. 6 hr p.r.n. pain [] Paxil 10/20/30/40 mg 1 p.o. q.d. max 50 mg q.d. [] OxyContin10/20/40/80 mg 1 p.o. q. 12 hr [] Duragesic Patch 25/50/75/100 mcg 1 patch q. 3 days [] Effexor XR 37.5/75/150 mg 1 p.o. q.d. [] Lidoderm Patch 1 patch 12 hours / day DIAGNOSIS: RADIOLOGY/IMAGING: MRI {W/CONTRAST}/ X-RAY / CT / BONE SCAN{3PHS/SPECT} AREA: EMG: LEFT / RIGHT / BILATERAL UPPER EXT / LOWER EXT FREQUENCY: QW / BIW / TIW WEEKS: 2 / 3 / 4 HANDOUTS: []EPIDURAL []FACET []MBB []RFA []IDET []PDD []DISCO MONTHS/YEARS []PT []INJ []TENS []SURGERY []MEDS []LAB []BRACES []MRI WORK STATUS:
May return to full work status (No restrictions)
May return to restricted work
OFF WORK
Not to lift over _____ pounds.
Not to lift over _____ pounds on a repetitive basis.
Not to carry over _____ pounds on a repetitive basis.
Not to push over _____ pounds on a repetitive basis.
Not to pull over _____ pounds on a repetitive basis.
Limited typing/keying to _____ hours/shift.
To avoid repetitive grasping or manipulating with
right hand
left hand
both hands.
To avoid repetitive stooping and bending.
To avoid twisting, turning and awkward positioning.
To avoid overhead lifting/reaching with -
right
left
both – upper extremity(ies)  1 – 2 minute breaks every half hour for position changes and stretching as needed.
No more than FOLLOW-UP 1 / 2 / 3 / 4 / 6 WEEKS / MONTHS / PRN / DISCHARGED

Source: http://www.swspineandsports.com/wp-content/uploads/2011/08/follow-up-form-080811.pdf