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WORK TIME: 8:30 - 5:00pm

Saturday and Sunday - CLOSED

Mail Us

[email protected]

CAll Us

(919) 220-0107

  • Home
  • About Us
  • Treatments
  • Our Staff
  • Resources
  • Insurance
  • Forms
  • Contact Us
  • Blogs
  • Ketamine Therapy
Menu
  • Home
  • About Us
  • Treatments
  • Our Staff
  • Resources
  • Insurance
  • Forms
  • Contact Us
  • Blogs
  • Ketamine Therapy
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Step 1 of 7

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  • Follow Up

    This questionnaire must be completed prior to your appointment with The HEAG Pain Management Center. Your careful answers will help us to understand your pain problem, and design the best treatment program for you. It is understandable that you might be concerned about what happens to the information you provide, as much of it is personal. Our records are strictly confidential and no outsider is permitted to see your case record without your written permission.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Duration of Pain

  • Quality of Pain

  • Timing of Pain

  • Goals

  • History of Present Illness – Pain Disability Index


    Pain disability index: The rating scales below are designed to measure the degree to which aspects of your life are disrupted by chronic pain. In other words, we would like to know how much your pain is preventing you from doing what you would normally do or from doing it as well as you normally would. Respond to each category by indicating the overall impact of pain in your life, not just when the pain is at its worst.
    For each of the 7 categories of life activity listed, please circle the number on the scale that describes the level of disability you typically experience. A score of 0 means no disability at all, and a score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain.
  • Dizziness Questionnaire

  • II. When you are “dizzy” do you experience any of the following sensations? You may circle as many yes responses as necessary.

  • III. Please fill in the blanks or circle the appropriate answer.

  • times per day / week / month / year.
  • seconds / minutes / hours / days.
  • IV. Do you have any of the following symptoms? Please circle Yes or No and circle the ear involved.

  • V. Have you experienced any of the following symptoms?

  • Review of Systems

SCHEDULE AN APPOINTMENT

Schedule an Appointment at one of our four locations.

Schedule

Get in Touch

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DURHAM LOCATION

2609 N. Duke St., Suite 303-B Durham, NC 27704 Phone: (919) 220-0107
Fax: (919) 220-7623

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GREENVILLE, NC

2245 H Stantonsburg Road, Greenville NC 27832
Phone: (252) 364-2830
Fax: (252) 364-2832

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GREENSBORO, NC

203 Pomona Drive Greensboro, NC 27408 Phone: (336) 282-0132
Fax: (336) 282-6962

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ARCHDALE, NC

106 Baker Road Archdale, NC 27263
Phone: (336) 434-3435
Fax: (336) 434-3437

Conditions we treat

  • Back Disorders
  • Neck Disorders
  • Atypical Facial Pain (Migraines)
  • Cluster Headache Pains
  • Sympathetic Dystrophy
  • Complex Regional Pain Syndrome
  • Failed Back Surgery Syndrome
  • Fibromyalgia
  • Vetebroplasty
  • Herniated Disc/Failed Disc Syndrome
  • Myofascial Pain
  • Osteroarthritis
  • Cancer Pain
  • Immune System Disorder Pain

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