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Reason for Visit
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What is the main reason for scheduling your visit?
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Where does it hurt? Include the side (left, right, or both).
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When did it start? Include any injury or change around that time.
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Is the pain constant or does it come and go? Explain
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Pain As of Right Now (Rate your pain from 0 to 10 (0 = no pain, 10 = worst pain imaginable).
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Average Pain in the Past Week (Rate your pain from 0 to 10 (0 = no pain, 10 = worst pain imaginable).
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Worst Pain in the Past Week (Rate your pain from 0 to 10 (0 = no pain, 10 = worst pain imaginable).
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What makes the pain worse? What helps?
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What does the pain make harder (walking, stairs, gripping, working, or sleeping)?
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What is one activity you would like to do more easily?
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What have you tried, and how much did it help?
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Past Medical History
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List your medical conditions, including any diagnosis for the painful area.
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Have you ever been diagnosed with any of the following medical conditions? Select all that apply.
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Have you ever been diagnosed with cancer?
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If yes, what type of cancer and when were you diagnosed?
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Past Surgical History
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Have you ever had surgery or a medical procedure?
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If yes, please list your surgeries or procedures and approximate dates.
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Do you have any implanted medical devices, such as a pacemaker, defibrillator, neurostimulator, or insulin pump?
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If yes, please describe the device, its location, and when it was implanted.
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Current Medications & Allergies
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Are you currently taking any prescription medications?
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Please list your current medications, dosages, and how often you take them.
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Please list any over-the-counter medications, vitamins, herbal products, or supplements you take. If none, enter None.
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Do you have any known allergies to medications?
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If yes, please list the medication(s) and describe your reaction(s).
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Do you have any other allergies, including latex, adhesive tape, or contrast dye? If yes, please list the allergy and reaction.
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Previous Cancer Treatments & Radiation History
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Have you ever received radiation therapy?
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If yes, what area of your body was treated, at which facility, and approximately when?
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Have you ever received chemotherapy?
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If yes, please provide the approximate dates and treatment facility.
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Have you ever received immunotherapy or targeted cancer therapy?
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If yes, please list the treatment name, dates, and facility, if known.
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Are you currently receiving any treatment for cancer?
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If yes, please describe your current treatment and treating physician.
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Family & Social History
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Has anyone in your immediate family been diagnosed with cancer?
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If yes, please list the family member, type of cancer, and approximate age at diagnosis.
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Smoking Status
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Which best describes your alcohol use?
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Is there anything about your living situation, transportation, or support system that may affect your ability to attend treatment?
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Current Symptoms
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Are you currently experiencing any of the following symptoms? Select all that apply.
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Please describe any symptoms, including where they occur, how long you have had them, and your pain level (0–10), if applicable.
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Additional Information
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Do you need help with transportation, mobility, or scheduling?
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Is there anything else you would like your care team to know before your appointment?
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