Back Pain Neck Pain ‘Circle’ Leg Pain Arm Pain All That Apply Both Both you have Pain (and/or) Pain If BOTH - Back + Leg Neck + Arm What % Percentage (of 100%) is: BACK v. LEG OR NECK v. ARM (e.g. 30% Back Pain & 70% Leg & Buttock Pain with the Adding up to 100%” – “Total (e.g. 60% Neck Pain & 40% Arm & Shoulder Pain with the Adding up to 100%” – “Total _______ % Pain vs. _______ % BACK LEG Right or Left or Both → _______ % NECK Pain vs. _______ % ARM Right or Left or Both →
Back Pain Neck Pain ‘Circle’ Leg Pain Arm Pain All That Apply Both Both If you have BOTH - Back + Leg Pain (and/or) Neck + Arm Pain What % Percentage (of 100%) is: BACK v. LEG OR NECK v. ARM (e.g. 30% Back Pain & 70% Leg & Buttock Pain – with the “Total Adding up to 100%” (e.g. 60% Neck Pain & 40% Arm & Shoulder Pain – with the “Total Adding up to 100%” _______ % BACK Pain vs. _______ % LEG → Right or Left or Both _______ % NECK Pain vs. _______ % ARM → Right or Left or Both
Patient%20Update%20Database.docx