Name:

Date:

1.

Please describe your current complaint or limitation:

2.

When did your problem begin? (specific date if possible)

3.

Describe how your problem began:

4.

Did you have surgery? Yes No
Date of surgery if applicable:

5.

Have you been treated for the same problem in the past? Yes No
If yes who did you see for your problem?
When and What type of treatment did you receive?

6.

What makes your pain better?
Nothing Lying down Standing Sitting Movement/Exercise Inactivity

7.

What makes your pain worse?
Nothing Lying down Standing Sitting Movement/Exercise Inactivity

8.

Are you presently working? Yes No
If yes, describe your job:

9.

Please list all significant medical history; heart, high blood pressure, cancer, ulcer, allergies, diabetes, etc. Everything is important!

10.

Please list all medications you are taking or have taken in the past few years.

11.

How intense is your pain at rest?
No pain 0 1 2 3 4 5 6 7 8 9 10 Unbearable

12.

How intense is your pain with no movement?
No pain 0 1 2 3 4 5 6 7 8 9 10 Unbearable

13.

What movements cause your pain to increase?

14.

Since this conditions began your symptoms have: Decreased Increased Not Changed

15.

Your symptoms are worse in:
Morning Afternoon Night Increased during the day Same all day