follow-up visit

Patient first name

Patient middle name

Patient last name

Birthdate

Chief complaint (reason for today's visit)

Provider:

Appointment Date

Appointment Time

Click on the images below to indicate where you have pain

FRONT BODY

Click or tap on the body image below to indicate where it hurts.

To clear your selections, click here.

BACK BODY

Click or tap on the body image below to indicate where it hurts.

To clear your selections, click here.

BODY: LEFT side VIEW

Click or tap on the body image below to indicate where it hurts.

To clear your selections, click here.

BODY: RIGHT side VIEW

Click or tap on the body image below to indicate where it hurts.

To clear your selections, click here.

Check the words that best describe your pain:

Is your pain:

Constant

Intermittent (on and off)

What makes your pain worse?

What makes your pain better?

Describe any side effects from your pain medications or treatments (including injections):

List any new pain treatments tried since your last visit?

How much relief have pain treatments (including injections) or medications provided since your last visit?
Please select the one percentage that shows how much relief you have received.

Interval Health

Has your Primary Care Provider changed since your last visit?

Yes

Has your Pharmacy changed since your last visit?

Yes

Please list any new medical conditions or changes in your mental or physical health status since your last visit:

Have your medications changed since your last visit?

Yes - I have added this medication

Yes - I have stopped taking this medication

Yes - I have changed the way I take this medication

Have you had a problem with alcohol or drug addiction since your last visit?

Yes

Select the number that describes how, during the past 24 hours, pain has interfered with each of the following functions.

Over the past 2 weeks have you been bothered by these problems?	Several days	More days than not	Nearly every day
Feeling nervous, anxious, or on edge	1	2	3
Not being able to stop or control worrying	1	2	3
Feeling down, depressed, or hopeless	1	2	3
Little interest or pleasure in doing things	1	2	3

REVIEW OF SYSTEMS

PLEASE CHECK ANY OF THE FOLLOWING YOU HAVE EXPERIENCED IN THE LAST MONTH:

By signing below, I attest that all health information is accurate to the best of my knowledge.

follow-up visit

Click on the images below to indicate where you have pain

FRONT BODY

BACK BODY

BODY: LEFT side VIEW

BODY: RIGHT side VIEW

Check the words that best describe your pain:

Interval Health

REVIEW OF SYSTEMS

Patient Agreement and Signature