|
What side of your body is affected?
|
What body part is your primary concern today?
|
|
When did your symptoms start?
|
Date of injury. Please state.
|
|
Was there an injury?
|
If yes, please describe the injury
|
|
Please describe your symptoms (all that apply).
• • •
|
Pain scale. Please select below.
|
|
Does the pain travel or radiate?
|
If yes, please select below.
• • •
|
|
Is the pain constant?
|
Any associated symptoms? (check all that apply)
• • •
|
|
What makes it worse?
• • •
|
If other, please list
|
|
What makes it better?
• • •
|
If other, please list
|
|
Has the nature of the pain since it began is...
|
Have you ever had this complaint before?
|
|
Please list other concerns below.
|
|
|
Past Medical History
|
|
|
Health conditions select all that apply.
• • •
|
|
|
Past Surgical History
|
|
|
Please list any surgical procedures.
|
|
|
Social History
|
|
|
What are your Hobbies or Sports?
|
What is your occupation?
|
|
Do you smoke?
|
Do you drink alcohol?
|
|
Marital status
|
What is your dominant hand?
|
|
Family Medical History
|
|
|
Please list relevant family medical conditions
|
|
