Location:

UPMC Aut Even Hospital
Freshford Road, Kilkenny Ireland R95 D370
Tel: 00353-56-7775146
Email: rheumatologyclinics@gmail.com

Language Options:

Pain Clinic

Please fill out this form to request a pain case review. One of our practice members will get back in touch with you soon.

YOUR DETAILS

YOUR CURRENT PROBLEM

PAIN SCALE

Using the diagram below, click on the crayon which best represents your pain and hold your mouse button to draw on the affected area of the body.

TREATMENTS
Have you had any treatment for your condition:

IMPORTANT INFORMATION : Please Click on either Yes or No.

Do you take any blood thinning medication: Yes No

Do you smoke Cigarettes: Yes No

Do you have Diabetes: Yes No

Have you have surgery on your Spine (Neck or Back) before: Yes No

Have you been diagnosed with cancer before: Yes No

Have you have any problems with Anaesthetics before: Yes No

PLEASE CLICK IF YOU HAVE HAD ANY OF THE FOLLOWING PROBLEMS:

MEDICATIONS: (For each medication—please type in the name, then Click on +Add more for another medication).

Enter Medication here

INVESTIGATIONS:

Please click on any investigations that you have had:

X-rays (Which joint(s) was the X Ray performed on and what was the result? Please include if a chest X ray was performed and what was the result?)

CT scan

MRI scan (Which joint(s) was the M.R.I performed on and what was the result?)

Nerve conduction study

Bone scan

Spinal Injections

Discogram

Myelogram

Ultrasound of joints (Which joint(s) was the ultrasound performed on and what was the result?)

Blood Test

Other

Have any doctors recommended surgery for your current problem:	Yes No

Have you previously attended a pain specialist?	Yes No

Have you previously attended a Rheumatologist?	Yes No

If you want a detailed medical report on your condition or a second opinion,please pay by credit card €250 inclusive of VAT and a comprehensive medical report will be e mailed to you : *	Yes No