Describe your current complaint(s) and how the problem began: Date of How long have you had this condition? onset: How would you describe the pain? Sharp Soreness Throbbing Tingling Dull Stiffness □ □ □ □ □ □ Burning Ache Weakness Numbness Shooting □ □ □ □ □ □ How would you rate the intensity of your pain? ( Circle the appropiate number) 1 2 3 4 5 6 7 8 9 10 (no pain) (moderate pain) (terrible/unbearable pain) How often is the pain present? Constant (81-100%) □ Frequent (51-80%) Occasional (26-50%) Intermittent (25% or less) □ □ □ Since your problem began is the pain: Getting worse Getting better Staying the same □ □ □ How did your problem begin? An auto accident Gradual Other type of accident □ □ □ A work accident Sudden No specific reason □ □ □ Please explain: What makes your problem better? Nothing Walking Standing Sitting Moving/exercising Lying down Inactivity □ □ □ □ □ □ □ What makes your problem worse? Nothing Walking Standing Sitting Moving/exercising Lying down Inactivity □ □ □ □ □ □ □ Were you previously treated for an earlier occurance of this same condition? If yes, by whom? MD Chiropractor Physical Therapist □ □ □ □ What were the approximate dates, type of treatment and the results? Please describe any serious accidents with approximate dates:
Describe your current complaint(s) and how the problem began: How long have you had this condition? Date of onset: How would you describe the pain? □ Sharp □ Soreness □ Throbbing □ Tingling □ Dull □ Stiffness □ □ Burning □ Ache □ Weakness □ Numbness □ Shooting How would you rate the intensity of your pain? ( Circle the appropiate number) 1 2 3 4 5 6 7 8 9 10 (no pain) (moderate pain) (terrible/unbearable pain) How often is the pain present? □ Constant (81-100%) □ Frequent (51-80%) □ Occasional (26-50%) □ Intermittent (25% or less) Since your problem began is the pain: □ Getting worse □ Getting better □ Staying the same How did your problem begin? □ An auto accident □ Gradual □ Other type of accident □ A work accident □ Sudden □ No specific reason Please explain: What makes your problem better? □ Nothing □ Walking □ Standing □ Sitting □ Moving/exercising □ Lying down □ Inactivity What makes your problem worse? □ Nothing □ Walking □ Standing □ Sitting □ Moving/exercising □ Lying down □ Inactivity Were you previously treated for an earlier occurance of this same condition? If yes, by whom? □ MD □ Chiropractor □ Physical Therapist □ What were the approximate dates, type of treatment and the results? Please describe any serious accidents with approximate dates: