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Lazarus Potential Client Screening Questionnaire

 

Please complete the following questionnaire to help us understand your pain. If we believe we can help you we will send you the client consulting agreement to sign and a link to pay the $7500 client consulting fee, and then move quickly to start developing your treatment plan and arranging for your pain specialist consultation.

1. Pain Location (Check all that apply)

1. Pain Location (Check all that apply)

2. Cause of Pain (Check all that apply or write in other causes)

2. Cause of Pain (Check all that apply or write in other causes)

3. Duration of Pain

How long have you been experiencing this pain?

3. Duration of Pain (How long have you been experiencing this pain?)

4. Number of Healthcare Providers Seen for Pain

How many healthcare providers have you seen for this pain?

4. Number of Healthcare Providers Seen for Pain (How many healthcare providers have you seen for this pain?)

5. Types of Healthcare Providers Seen (Check all that apply)

5. Types of Healthcare Providers Seen (Check all that apply)

6. Treatments Tried (Check all that apply)

6. Treatments Tried (Check all that apply)
Interventional Pain Procedures (Check all that apply and specify if known)

7. Current Insurance Provider

What is your current health insurance provider?

7. Current Insurance Provider

8. Insurance Denials

Has your insurance denied any recommended treatments?

Multi choice

Additional Comments

Is there anything else you would like us to know about your pain condition or treatment history?

Thank you for completing this questionnaire. This information will help us determine the best approach for managing your pain.

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