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Questionnaire Musculo Skeletal Pain

Musculo Skeletal questionnaire​​​​​​​​​​​​​​ 

Muscle aches, sprains, strains, TMJ, and joint pain are common and often result from overuse, minor injuries, or the natural wear and tear associated with osteoarthritis. Most cases can be safely managed with rest, supportive care, and time. However, pain that is sudden, severe, worsening over time, associated with swelling, redness, warmth, fever, inability to move the joint or limb, numbness, or signs of infection may indicate a more serious condition. If you experience these symptoms or if your pain does not improve with basic care, it is important to seek an in-person medical evaluation for further assessment.
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You chose not to proceed with this evaluation. No further action is required.
​​​​​​​
If you change your mind or need care later, you’re welcome to start a new visit at any time.

To ensure your provider can safely evaluate your symptoms, we’ll ask a few questions about your health history, medications, and allergies.
Please identify all your current medical conditions
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Please list all your current medications including dosages
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Please list all of your known allergies
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What you were seeking help for:

• Musculo Skeletal

Why this happens

Certain antibiotics commonly used for Musculo Skeletal are not recommended during pregnancy or breastfeeding, and a provider may need to perform additional testing or choose medication based on an in-person assessment.
Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.
I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.

I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.

I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
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By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
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What is your height?
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What is your weight in pounds
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Tell us about the other location of your arthritis
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Tell us about the other treatments that you have tried for your arthritis
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Please describe any complications or side effects
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What symptoms are you currently experiencing? (Select all that apply)

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Please describe your other symptoms
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Please list any current treatments that you’re presently taking for this condition
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Please describe
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Tell us about the other treatments that you have tried for your symptoms.
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[HideColumn 66 in #o1e6f6050fd59] [IfField f2369 not ''][ShowElement 81 in #o1e6f6050fd59][HideElement 82 in #o1e6f6050fd59][/IfField] [IfAnchor #f2369.01][ShowBlock #od927b4440465][HideBlock #o1e6f6050fd59][Redirect #donetop][/IfAnchor] [SyncFields f2369] [Validate #o1e6f6050fd59-f2323 IBAN “Please enter a valid IBAN” prevent=yes]
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Please describe any complications or side effects.
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What symptoms are you currently experiencing? (Select all that apply)

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Please describe your other symptoms:
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Please list any current treatments that you’re presently taking for this condition
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What other information or questions do you have for the doctor?
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Please attest to the following confirming that all information you have provided to us is true and complete.

I verify that I am the patient and that I have answered the questions asked in this intake form.  I confirm that I have reviewed and understood all the questions asked of me.  I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor.  I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
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Purpose of Treatment:

You are seeking treatment for muscle pain, strains, sprains, and/or arthritis. These conditions may cause joint or muscle discomfort, stiffness, swelling, or limited mobility. The goal of treatment is to reduce pain and inflammation, support healing, restore function, and improve your overall quality of life. Management may include medications such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, corticosteroids, muscle relaxants, topical agents, or other therapies tailored to your condition.

Potential Benefits:

 
  • Relief from muscle or joint pain and stiffness
  • Reduced inflammation and swelling
  • Enhanced healing of strained or sprained muscles
  • Improved physical function and range of motion
  • Better ability to perform daily activities
 
    Potential Risks and Side Effects:

    While treatments for muscle and joint conditions are generally safe and effective, they may carry risks and side effects depending on the medication or therapy used. These may include, but are not limited to:

    NSAIDs (e.g., ibuprofen, naproxen):

     
    • Stomach upset, ulcers, or gastrointestinal bleeding
    • Increased blood pressure
    • Kidney dysfunction or failure
    • Cardiovascular risks (heart attack or stroke)
      
      Acetaminophen:
       
      • Liver damage (especially at high doses or with alcohol use)
       
        Corticosteroids (oral or injection):
         
        • Increased blood sugar levels
        • Weight gain
        • Bone thinning (osteoporosis) with long-term use
        • Increased risk of infection
         
          Muscle relaxants:
           
          • Drowsiness or dizziness
          • Dry mouth
          • Risk of dependency with prolonged use
           
            Alternatives to Medication:

            • Rest, ice, compression, elevation (RICE) for acute strains or sprains
            • Physical therapy or guided rehabilitation
            • Stretching and strengthening exercises
            • Use of assistive devices (e.g., braces, orthotics)
            • Weight management and ergonomic adjustments
            • Referral to a specialist for advanced or interventional therapies
             
              Your Responsibilities:

              • Inform your healthcare provider about all current medications and supplements
              • Report any new or worsening symptoms or side effects promptly
              • Follow the prescribed treatment plan, including home care instructions
              • Notify your provider if you are pregnant, breastfeeding, or planning to become pregnant

                Consent Statement:

                By agreeing to this treatment, you acknowledge that you understand the potential risks and benefits of the medications and therapies recommended for arthritis, muscle strain, or sprain. You may withdraw your consent at any time.

                Acknowledgment:

                ​​​​​​​I understand the information provided above and consent to receive treatment for my muscle or joint condition, including the use of medications and therapies discussed.
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                Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.

                What you were seeking help for:

                • Musculo Skeletal

                Why this happens

                Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.
                Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.

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