CARY ADULT MEDICINE

Please complete this form for an e-visit for any neck,mid or lower back pain complaints

Name * Date of Birth * What type of insurance do you have? Have you completed an E-visit in past 6 months Approximate Date of your last office visit Are you allergic to any of the following? Date Back Pain Started Location of Pain Is pain mostly on ? Did you fall or have any trauma to the area? Do you have any blood in your urine? How did you hurt your back ? Have you had any previous back surgery ? If Yes to previous surgery describe location and type of surgery Have you taken any medications for pain? If you have taken medications which one and did they help? Does the pain radiate down your leg or arms? If yes then radiates down What makes pain worse? Is pain worse when you wake up? Have you tried? Has your had an x-ray on your back? Have you ever had an MRI of your back? Have you ever had a herniated disk? Is your back pain Rate your pain on 1 to 10 scale (10 worst) Any other info you would like to include? Best Contact Method Best phone number or email