First Name

Last Name

Date of Birth

What problem brings you here today? What problem brings you here today? Back Pain Hip Pain Neck Pain Shoulder Pain Knee Pain

Other problem

When did it start? When did it start? Less than 3 months ago More than 3 months ago More than a year ago

What makes the pain worse? What makes the pain worse? Bending forward Twisting Sitting for long period Standing for long period Walking Running Lifting Reaching Sleeping on Affected Side Looking Left or Right

What makes the pain better? What makes the pain better? Sitting down Laying down Walking Medication Ice Heat Physical therapy Nothing

What diagnostic tests have you had for this problem? What diagnostic tests have you had for this problem? X-ray MRI CT Scan EMG / NCS Bone Scan None

What treatments have you had for this problem? What treatments have you had for this problem? Massage Injections Physical Therapy Psychological Chiropractic Surgery None

What is your pain level today? 0 = No Pain What is your pain level today? 0 = No Pain012345678910

What is your WORST pain level? 0 = No Pain What is your WORST pain level? 0 = No Pain012345678910

Please describe the pain Please describe the pain Dull Achy Burning Stabbing Numbness Tingling Pulling Cramping Tightness

What is the course of the pain? What is the course of the pain? Constant Comes and Goes Getting Worse Getting Better Staying about the Same

List Allergies to Medications

Family History Family History Cancer Heart disease Stroke Diabetes Hypertension Bleeding disorder

Tobacco Use Tobacco Use Current Quit Never

Illicit Drug Use Illicit Drug Use Current Quit Never

Opioid Use Opioid Use Current Past Never

Alcohol Use Alcohol Use None 1-2 per week 3-5 per week 6 or more per week

General Symptoms General Symptoms Night pain Fevers Unintentional weight loss

Neuro Neuro Numbness/Tingling Weakness Headaches Dizziness

Chest Symptoms Chest Symptoms Chest Pain Palpitations

Respiratory Respiratory Shortness of breath Wheezing Coughing

Digestive Digestive Nausea Vomiting Black stools Loss of Control of Stools

Urinary Urinary Loss of control of urine Urinary frequency Urinary urgency

Musculoskeletal Musculoskeletal Joint pain Joint Swelling Joint Redness Muscle Pain