Follow-up visit

Schedule a follow-up visit with Dr. Patrice Langlois to assess your progress and determine the next steps in your treatment plan.

    PERSONAL DATA

    Choose the clinic for your visit:

    MEDICAL QUESTIONNAIRE

    Reason for consultation :

    How long has the pain been more severe?

    Choose the sensation of pain

    Is the pain :

    Please rate your pain by choosing the one number that best describes your pain at its WORST in the past 24 hours.

    Please rate your pain by choosing the one number that best describes your pain at its LEAST in the last 24 hours.

    Please rate your pain by choosing the one number that best describes your pain on AVERAGE.

    Please rate your pain by choosing the one number that tells how much pain you have RIGHT NOW.

    During the last 24 hours, what RELIEF have you received from the treatments or medications you are taking? Indicate the number of improvement obtained.

    Under what circumstances is the pain aggravated?

    Indicate the number that best describes how, during the past 24 hours, pain has interfered with your:

    A. General activity
    B. Mood
    C. Walking ability
    D. Normal work (includes both work outside the home and housework)
    E. Relations with other people
    F. Sleep
    G. Enjoyment of life

    Upload your medical reports of your X-rays/images, if you have them (magnetic resonance, CT scan, x-ray):

    Find out how we can help.

    We're committed to compassionate care and giving our patients the tools they need to live life to the fullest despite the challenges of chronic pain.

    Contact us today.