What caused your symptoms? Unknown Injury Other: □ □ □ What % of your symptoms are in the BACK and LEG? What % of your symptoms are in each LEG? (please (please check one box) check one box) Back 0%, Leg 100% No LEG symptoms □ □ Back 10%, Leg 90% 0%, Left 100% □ □ Back 25%, Leg 75% Right 10%, Leg 90% □ □ Back 50%, Leg 50% Right 25%, Left 75% □ □ Back 75%, Leg 25% Right 50%, Left 50% □ □ Back 90%, Leg 10% Right 75%, Left 25% □ □ Back 100%, Leg 0% Right 90%, Left 10% □ □ Right 100%, Left 0% □ Where in your LEG do you have in your LEG do you have Where in your LEG do you have PAIN or TINGLING? NUMBNESS? WEAKNESS? Right Left Right Left Right Left None None None None None None □ □ □ □ □ □ Buttock Buttock Buttock Buttock Buttock Buttock □ □ □ □ □ □ back Thigh, back Thigh Thigh Thigh Thigh □ □ □ □ □ □ Thigh, front Thigh, front Ankle Ankle □ □ □ □ □ □ Calf Calf Calf Calf Calf Calf □ □ □ □ □ □ Foot Foot Foot/toes Foot/toes Foot Foot □ □ □ □ □ □ Neck Only Patient Name (print): Date: Reason for Today’s Visit: Symptoms: Back pain Leg pain Neck pain Arm pain Numbness Weakness Scoliosis □ □ □ □ □ □ □ □
What caused your symptoms? □ Unknown □ Injury □ Other: What % of your symptoms are in the BACK and LEG? (please check one box) □ Back 0%, Leg 100% □ Back 10%, Leg 90% □ Back 25%, Leg 75% □ Back 50%, Leg 50% □ Back 75%, Leg 25% □ Back 90%, Leg 10% □ Back 100%, Leg 0% What % of your symptoms are in each LEG? (please check one box) □ No LEG symptoms □ 0%, Left 100% □ Right 10%, Leg 90% □ Right 25%, Left 75% □ Right 50%, Left 50% □ Right 75%, Left 25% □ Right 90%, Left 10% □ Right 100%, Left 0% Where in your LEG do you have PAIN or TINGLING? Right Left □ None □ None □ Buttock □ Buttock □ back □ Thigh, back □ Thigh, front □ Thigh, front □ Calf □ Calf □ Foot □ Foot in your LEG do you have NUMBNESS? Right Left □ None □ None □ Buttock □ Buttock □ Thigh □ Thigh □ □ Ankle □ Calf □ Calf □ Foot/toes □ Foot/toes Where in your LEG do you have WEAKNESS? Right Left □ None □ None □ Buttock □ Buttock □ Thigh □ Thigh □ □ Ankle □ Calf □ Calf □ Foot □ Foot Neck Only Patient Name (print): Date: Reason for Today’s Visit: Symptoms: □ Back pain □ Leg pain □ Neck pain □ Arm pain □ Numbness □ Weakness □ Scoliosis □
Patient-Paperwork.docx