Follow Up Evaluation
Patient Name
DOB
Date of Last Visit
Type in the letter(s) which correspond to the area(s) in which your pain is located
How often do you have your pain? (Check One)
Constantly (100% of the time)
Frequently (75% of the time)
Intermittently (50% of the time)
Occasionally (25% of the time)
How would you describe your pain? (Check as many as needed)
Burning
Throbbing
Dull, Aching
Shooting
Sharp
Cramping
Pressure
Electric-like
Cutting
Numbness
Pins and Needles
Other
Select the number which most closely represents your pain intensity (0=no pain, 10=most severe pain)
0
1
2
3
4
5
6
7
8
9
10
Review of Systems (check if you have any of the following)
Constitutional: fevers/chills, night sweats, unplanned weight loss, fatigue
Skin: rash, itching (pruritus), dryness
Gastrointestinal: nausea/vomiting, constipation, diarrhea, incontinence of stool
Genitourinary: blood in urine (hematuria), decreased libido, incontinence of urine