16) List all medications you have tried in the past that did not relieve your pain or caused bad side effects. Please list what side effect occurred next to the medication. 17) Please answer the following questions if your problem is the result of an injury: Mark only one: I never had back/neck problems before this injury. □ I had back/neck problems before, and this injury made the problem worse. □ Mark all that apply: This injury occurred at work. □ This injury did not occur at work. □ I have filed a claim through worker’s compensation. □ I have pursued or will pursue action as a result of this injury. □
16) List all medications you have tried in the past that did not relieve your pain or caused bad side effects. Please list what side effect occurred next to the medication. 17) Please answer the following questions if your problem is the result of an injury: Mark only one: □ I never had back/neck problems before this injury. □ I had back/neck problems before, and this injury made the problem worse. Mark all that apply: □ This injury occurred at work. □ This injury did not occur at work. □ I have filed a claim through worker’s compensation. □ I have pursued or will pursue action as a result of this injury.
new-patient-packet.docx