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Regenerative Medicine
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Cervical Radiculopathy
Complex Regional Pain Syndrome
Degenerative Disc Disease
Disc Herniations
Osteoarthritis
Post-Laminectomy Syndrome
Spinal Stenosis
Vertebral Compression Fractures
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Patient Forms
Locations
Stockbridge
Hapeville
Roswell
Decatur
Lawrenceville
Contact Us
About Us
Meet Our Doctors
Accepted Insurance
Testimonials
Areas We Serve
Services
Federal Workers’ Comp Assistance
Interventional Pain Procedures
Personal/Auto Injury Assistance
Physical Therapy & Rehabilitation
Regenerative Medicine
Conditions
Cervical Radiculopathy
Complex Regional Pain Syndrome
Degenerative Disc Disease
Disc Herniations
Osteoarthritis
Post-Laminectomy Syndrome
Spinal Stenosis
Vertebral Compression Fractures
Resources
Blog
FAQs
Other Resources
Patient Forms
Locations
Stockbridge
Hapeville
Roswell
Decatur
Lawrenceville
Contact Us
Accepted Insurance
Book Appointment
6787827999
Pain Profile Form
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Pain Profile Form
Pain Profile Form
First Name
(Required)
Last Name
(Required)
Sex
(Required)
Male
Female
Date of Birth
(Required)
MM slash DD slash YYYY
Email
(Required)
Height
(Required)
Current Weight (lbs)
(Required)
Goal Weight (lbs)
(Required)
Address
(Required)
City
State
(Required)
Zipcode
(Required)
Please Answer the Following:
What Is Your Greatest Area of Pain?
(Required)
What Other Areas of Your Body Give You Pain?
(Required)
Have You Been Given a Diagnosis in the Past?
(Required)
Yes
No
If Yes, What Was Your Diagnosis?
Untitled
What Made You Want to Do Something About Your Pain Today?
(Required)
Please Check the Box if You Have or Have Had Any of the Below:
(Required)
Cancer
Platelet Dysfunction Sundrome
Hemodynamic Instability
Corticosteroid Injection at Location of Pain Within 1 Month
Acid Reflux Disease
Pain in the Legs
Carpal Tunnel
Arthritis
Immune System Disease
Lung/Pulmonary Disease
Stroke
Neck Pain
Disease
Critical thrombocytopenia
Consistent Use of NSAID Within 48 Hours of Procedure
Recent Fever or Sickness
Numbing/Tingling in Arms/Hands
Pain in the Feet
Hemoglobin Level Below 10 g/dL
Bone Problems
Gastrointestinal Disease
Migraines
Neuromuscular Disease
Tension Headaches/Other Headaches
Kidney Metabolic Disease
O Cuteoporos
Systemic Use of Corticosteroids Within 2 Weeks
Sleeping Disorders
Numbing/Tingling in Legs/Feet
Digestive Problems
Diabetes
Heart Disease
Hypertension/High Blood Pressure
Pancreas
Low Back Pain
Platelet Count Under 105
Which of the Above Bothers You the Most?
How Long Have You Had It?
How Often Does It Occur?
What Activities Would You Like to Do if this was not a Problem?
What Have You Tried to Relieve/Get Rid of this Problem?
Medications
Physical Therapy
Nutrition
Stretching
Exercise
Chiropractic Care
Nothing
Other
Patient Signature
(Required)
Date
MM slash DD slash YYYY
Provider Signature
(Required)
Date
MM slash DD slash YYYY
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Email
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Find Your Relief Today
About Us
Meet Our Doctors
Accepted Insurance
Testimonials
Areas We Serve
Services
Federal Workers’ Comp Assistance
Interventional Pain Procedures
Personal/Auto Injury Assistance
Physical Therapy & Rehabilitation
Regenerative Medicine
Conditions
Cervical Radiculopathy
Complex Regional Pain Syndrome
Degenerative Disc Disease
Disc Herniations
Osteoarthritis
Post-Laminectomy Syndrome
Spinal Stenosis
Vertebral Compression Fractures
Resources
Blog
FAQs
Other Resources
Patient Forms
Locations
Stockbridge
Hapeville
Roswell
Decatur
Lawrenceville
Contact Us
Get Relief Now
