What are your symptoms or complaints?

Was there a specific cause to your condition or pain? If yes, what was the cause?

When (approximately) was the onset of your condition or pain?

Are you currently under the care of a health professional for your situation? If yes, please describe.

Are you being treated for any health condition other than that stated above? If yes, please describe.

Have you had any surgeries, treatments or special procedures for your condition or pain? If yes, please describe and state approximate date of last contact

What other surgeries, treatments or special procedures have you undergone in the past? Please describe and state approximate date.

What treatments or procedures from health professionals are you undergoing now?

Have you ever received treatment for any drug addiction? (Please indicate street or prescription and approximate date.)

Have you even been denied insurance coverage for any medical reason? Please describe.

Have you ever visited a medical professional for any psychological problems such as depression, anxiety, panic attacks, obsessive compulsive behavior or the like? If yes, please describe including dates.

What medications, prescription or over-the-counter are you currently taking?

What medications for your condition or pain have you found most effective in the past?

What medications that you have taken have given you negative reactions?

Do you take any "street" drugs? If yes, which ones and how often?