FOLLOW UP QUESTIONNAIRE
Name: _______________________________________________________________Date: ________________________________
Primary Care Physician: _________________________________Referring Physician: ____________________________________
Have you changed your primary care physician?----------------------------------------------------------------------------------------YES---NO
Have there been any changes to your employment/occupation?-----------------------------------------------------------------------YES---NOIf yes, please note changes:______________________________________________________________________________________________________________________________________________________________________________________________
Are you currently receiving worker’s compensation?-----------------------------------------------------------------------------------YES---NO
Are you currently off work as a result of your pain?-------------------------------------------------------------------------------------YES---NO If yes, for how long? _________________________________________________________________________________________
Are you presently involved in a lawsuit regarding your pain?--------------------------------------------------------------------------YES---NO
What activities are you unable to do because of your pain?_____________________________________________________________________________________________________________________________________________________________________
What activities are you now able to do after treatment (i.e., medication, injections, etc.)?____________________________________________________________________________________________________________________________________________________________________________________________________________________
Is your pain the result of a motor vehicle accident?--------------------------------------------------------------------------------------YES---NO
Have there been any changes in your medical condition since your last visit?-------------------------------------------------------YES---NOIf yes, note changes:_____________________________________________________________________________________________________________________________________________________________________________________________________
Have you been to the emergency room or been hospitalized since your last visit with us?-----------------------------------------YES---NOIf yes, please explain:_____________________________________________________________________________________________________________________________________________________________________________________________________
Please list your current medications: Drug Name How often Prescribing Physician
1) ________________________________________________________________________________________________________
2) ________________________________________________________________________________________________________
3) ________________________________________________________________________________________________________
4) ________________________________________________________________________________________________________
5) ________________________________________________________________________________________________________
Are you currently taking any blood thinners?--------------------------------------------------------------------------YES----NO Please circle any that apply: Fish Oil, Cod Liver Oil, Omega 3’s, Coumadin, Warfarin, Plavix, Heparin, Ticlid, Aggrenox, Lovenox, Pletal, Trental, Aspirin or Other: __________________________________________________
Please circle on the 0-10 scale below how severe your pain is today:
(NONE) 0 1 2 3 4 5 6 7 8 9 10 (Worst Ever)
How much has your pain changed since your last visit with us?
Decreased Considerably Decreased Mildly Same Increased Mildly Increased Considerably Rev 06.05.08
FINAL TEXT: 24-July-2012 ARCOXIA® W (etoricoxib) PRESCRIBING INFORMATION Refer to Summary of Product Characteristics before prescribing Adverse events should be reported. Reporting forms and information can be found at reported to MSD (tel: 01992 467272). PRESENTATION Tablets: 30 mg, 60 mg, 90 mg and 120 mg tablets each containing 30 mg, 60 mg, 90 mg or 120 mg of etoric
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