Pain Management Survey

Type of Pain, Injury, or Condition

Treatments Already Tried (check all that apply) Treatments Already Tried (check all that apply) None Hydrotherapy (Heating Pad or Ice Pack) NSAIDs (Ibuprofen, Aleve, Aspirin) Tylenol Physical Therapy Acupuncture Chiropractic Cortison (Steroid Injection) Narcotics (Vicodin, Percocet, etc.) Other Drugs (Gabapentin, Neurontin, etc) Facet Injections Nerve Blocks RFA (Radio Frequency Ablation) Viscosupplementation (Synvisc, Hyaluronic Acid, Rooster Comb Injections) Arthoscopic Surgery (Clean Up) Partial Joint Replacement Tissue Graft (Cadaver or Porcine) Total Joint Replacement Total Joint Replacement

Any other treatments not listed above?

Have you been told you need a joint replacement now or in the future? Have you been told you need a joint replacement now or in the future?YesNo

Do you have any metal screws or plates? Do you have any metal screws or plates?YesNo

Imaging Studies (check all that apply) Imaging Studies (check all that apply) None X-Ray X-Ultrasound CT Scan MRI

Any other imaging studies not listed above?

Additional comments or concerns?

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