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Survey
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How did you hear about the Stellate Ganglion Block procedure?
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How Did You Hear About Us?
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Emergency Contact Information
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Emergency Contact Person
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Emergency Contact Number
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Emergency Contact Relationship
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Military Status
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Have you served in the armed forces?
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If yes, select status
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Which branch(es)?
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List dates.
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Gender
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Please Select One
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Employment
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What is your employment status?
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Self Assessment
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In your words, describe cause of symptoms.
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When did these symptoms begin?
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What causes them to feel better?
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What causes them to feel worse?
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Please list what you view to be the reason for your mental trauma
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If other, please provide details.
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Specific History Question
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Select all that you have a history of:
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Healthcare Providers
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Primary Care
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Name
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Phone
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Email
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Fax
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Address
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Date of Last Visit
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Psychologist
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Name
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Phone
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Email
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Fax
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Address
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Date of Last Visit
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Psychiatrist
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Name
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Phone
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Email
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Fax
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Address
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Date of Last Visit
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Counselor / Other
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Name
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Phone
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Type
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Address
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Date of Last Visit
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Name
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Phone
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Type
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Address
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Date of Last Visit
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Additional
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Health Questions
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Smoking
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Have you ever smoked?
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If yes, when did you start?
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Do you smoke now?
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Cigarettes
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Frequency?
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Cigars
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Frequency?
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Pipe
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Frequency?
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Alcohol
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Do you drink alcohol?
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If so, how much?
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Have you ever had a problem with alcohol?
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If yes, please provide details.
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Have you ever had cirrhosis of the liver?
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If yes, please provide details.
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Caffeine
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Do you consume drinks with caffeine?
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Which drinks?
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Frequency?
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Other?
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Recreational Drugs
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Do you use any recreational drugs?
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If yes, please provide details.
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Do you use marijuana?
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If yes, please provide details.
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Cancer
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Self
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Have you been diagnosed with cancer?
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If yes, please provide details.
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Undergoing Cancer Treatment?
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If yes, please provide details.
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Family
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Cancer Type
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Relationship
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Cancer Type
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Relationship
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Additional Cancer History
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Allergies
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Allergies
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If other, please list
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Anesthesia
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Any problems with anesthesia?
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If yes, please provide details.
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Any concerns with anesthesia?
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If yes, please provide details.
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Medications
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Prescriptions
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Prescription Name
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Dose
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Frequency
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Date Started
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Prescription Name
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Dose
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Frequency
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Date Started
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Prescription Name
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Dose
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Frequency
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Date Started
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List Additional Prescriptions
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Over The Counter
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OTC Name
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Dose
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Frequency
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Date Started
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OTC Name
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Dose
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Frequency
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Date Started
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List Additional OTC's
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Supplements
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Supplement Name
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Dose
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Frequency
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Date Started
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Supplement Name
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Dose
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Frequency
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Date Started
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List Additional Supplements
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Surgical History
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Surgery Type
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Surgery Date
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Surgery Type
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Surgery Date
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List Additional Surgeries
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Psychiatric
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Any Psyciatric Hospitalizations?
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Details & Dates
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Psychiatric Treatments
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List Other(s)
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Have you ever been convicted of a crime?
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Please give details:
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Vital Statistics
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Height
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Weight
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History Questionnaire
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General
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If yes, please provide details.
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Neurological
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If yes, please provide details.
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Hematologic
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If yes, please provide details.
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Infectious Disease
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If yes, please provide details.
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Psychiatric
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If yes, please provide details.
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Anti-Inflammatory / NSAIDS
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If yes, please provide details.
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Blood Thinners
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If yes, please provide details.
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Musculoskeletal
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If yes, please provide details.
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Cardiovascular
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If yes, please provide details.
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Peripheral-Vascular
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If yes, please provide details.
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Gastrointestinal
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If yes, please provide details.
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Endocrine
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If yes, please provide details.
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Respiratory
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If yes, please provide details.
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Additional
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Please include anything important you think we have missed.
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Helping Others
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Would you be willing to provide a written testimonial?
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Would you be willing to provide a video testimonial?
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Would you be willing to speak to prospective patient(s) about your experience??
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