Name *

First Name

Last Name

Current Assesment of Pain *

0= No Pain, 2 = Mild Pain, 4= Moderate Pain, 6= Severe Pain, 8 = Very Severe Pain, 10 = Worst Possible Pain

0

1

2

3

4

5

6

7

8

9

10

Worst possible pain in the past week: *

0= No Pain, 2 = Mild Pain, 4= Moderate Pain, 6= Severe Pain, 8 = Very Severe Pain, 10 = Worst Possible Pain

1

2

3

4

5

6

7

8

9

10

Worst possible pain in the past month *

0= No Pain, 2 = Mild Pain, 4= Moderate Pain, 6= Severe Pain, 8 = Very Severe Pain, 10 = Worst Possible Pain

1

2

3

4

5

6

7

8

9

10

Least amount of pain in the last week: *

0= No Pain, 2 = Mild Pain, 4= Moderate Pain, 6= Severe Pain, 8 = Very Severe Pain, 10 = Worst Possible Pain

1

2

3

4

5

6

7

8

9

10

Least amount of pain in the last month: *

0= No Pain, 2 = Mild Pain, 4= Moderate Pain, 6= Severe Pain, 8 = Very Severe Pain, 10 = Worst Possible Pain

1

2

3

4

5

6

7

8

9

10

Have you recently noted any of the following? *

Weight Loss

Weight Gain

Fever, Chills or Sweats

Dizziness/Fainting

Numbness or Tingling

Weakness

Fatigue

Nausea or Vomiting

Bowel or Bladder Problems

Problems Sleeping

Changes in Vision

Changes in Hearing

None of the above

Have you ever smoked? *

No

Yes

Date Of Injury and/or surgery

MM

DD

YYYY

Date of Injury and/or surgery

MM

DD

YYYY

Date of Injury and/or surgery

MM

DD

YYYY

Which of the following over the counter medications have you taken in the last 2 weeks? *

Aspirin

Tylenol

Antacids

Laxatives

Decongestants

Antihistamines

Advil/Motrin/Aleve/Ibuprofen

Vitamins/Mineral Supplements

Herbal Remedies/Supplements

None of the above

In the past three months, have you seen any of the following? *

Osteopath

Physical or Occupational Therapist

Chiropractor

Dentist

Psychiatrist/Psychologist

Specialist

None of the above

Have you had any of the following procedures for this condition? *

X-Ray

Bone Scan

Nerve Conduction Study

Arteriogram

MRI

CT Scan

None of these

You *

Asthma

Thyroid Problems

High Blood Pressure

Depression

Tuberculosis

Kidney Problems

Epilepsy

Cancer

Emphysema/Bronchitis

Chemical Dependency (i.e. alcoholism)

Diabetes

Cardiac Problems

Hepatitis

Stroke

Anemia

Osteoporosis/Osteopenia

None of the above

A family Member *

Asthma

Thyroid Problems

High Blood Pressure

Depression

Tuberculosis

Kidney Problems

Epilepsy

Cancer

Emphysema/Bronchitis

Chemical Dependency (i.e. alcoholism)

Diabetes

Cardiac Problems

Hepatitis

Stroke

Anemia

Osteoporosis/Osteopenia

None of the above

By typing in your first and last name and today's date, you are saying that the information above is correct. *

First Name

Last Name

Today's Date

MM

DD

YYYY