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  • Our Company
    • Careers
    • Mission
    • Success Stories
    • Technology Solutions
  • Our Services
    • Agency & Brokerage Services
    • Cost Containment
    • Government Services
    • International/Domestic Sevices
    • Medical Case Management
    • Medical Claims Management
    • Provider Networks/Services
    • Self-Funded Programs
    • Specialty Services
      • House Calls
      • Medical Escort Service
      • Second medical Opinion
      • White Glove Service
    • T.P.A. Services
  • Contact Us
  • International Centers of Excellence
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  • PayerFusion Forms

Low Back Pain Questionnaire

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  2. Low Back Pain Questionnaire

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Please take a few minutes to complete this form. This information will be very helpful in establishing a diagnosis and assist in developing a treatment plan for you. This information will be placed into your records and be maintained in strict confidence

MM slash DD slash YYYY
Do you smoke?
Is your present condition accident related?
Have you seen any specialists for this condition in the past (such as a Chiropractor, Acupuncturist, Physical or Occupational Therapist, Surgeon, etc.)?
Do you have any medical conditions?
If yes, please list type and frequency:
Do you have any allergies?

How long have you had:

Have you been hospitalized for this condition?
Have you had prior spine surgery?

If yes, please list:

How long was the duration of this relief?

This questionnaire has been designed to provide information as to how your back pain has affected your ability to manage in everyday life. Please answer every question by placing a mark in the one option that best describes your condition today. We realize you may feel that 2 of the statements may describe your condition, but please select only one option that most closely describes your current condition

Pain Intensity
Personal Care (e.g., Washing, Dressing)
Lifting
Walking
Sitting
Standing
Sleeping
Social Life
Traveling
Employment / Homemaking
Please submit completed form to ConciergeCare@payerfusion.com
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