Get the free Consultation Form Spine Center - Dartmouth-Hitchcock Medical ... - dhmc

Phone: (603) 650-2225 Fax: (603) 650-6322 Consultation Form Spine Center Providers Patient Name: Orthopedic SURGERY DOB: Soc. Sec #: William Abdul, MD, MS So hail Mira, MD, MPH Di lip Gupta, MD James

How to fill out consultation form spine center

How to Fill out a Consultation Form at a Spine Center:

Start by providing your personal information:

1. Enter your full name, including any middle names or initials.
2. Include your date of birth.
3. Provide your contact information, including your phone number and email address.
4. Indicate your current address.

Mention your medical history:

1. Specify any previous surgeries or treatments related to your spine.
2. Note any existing conditions or diagnoses.
3. List any medications you are currently taking.

Detail your symptoms and concerns:

1. Explain the specific issues you are experiencing with your spine.
2. Describe the intensity and frequency of your symptoms.
3. Mention any relevant incidents or accidents that may have caused your spine problems.

Note your lifestyle and daily activities:

1. Describe your occupation and any physical demands it may have.
2. Indicate your level of physical activity, such as exercise routines or sports participation.
3. Highlight any factors that may contribute to your spine condition, such as heavy lifting or prolonged sitting.

Provide insurance and payment information:

1. Mention your health insurance provider, policy number, and any authorization requirements.
2. Specify if you have any worker's compensation claims or personal injury cases related to your spine.
3. Discuss your preferred payment method and any financial concerns.

Who needs a consultation form at a spine center?

1. Individuals seeking medical evaluation and treatment for spine-related issues.
2. Patients with spine conditions or injuries, such as herniated discs, scoliosis, or spinal stenosis.
3. Individuals experiencing symptoms like back pain, neck pain, numbness, or limited mobility.
4. People with a history of spine surgeries or treatments who require further medical advice.

Remember, the consultation form at a spine center plays a crucial role in providing accurate and comprehensive information to your healthcare provider. Filling it out thoroughly and accurately will help the medical team better understand your needs and devise an appropriate treatment plan.

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