Current Complaints
Name
First Name, Ml
Last Name
Date of birth
-
Month
-
Day
Year
Date
Please indicate the body part(s) to be evaluated today
*
Neck
Low back
Mid back
Shoulder
Elbow
Wrist
Hand
Hip
Knee
Ankle
Foot
Other
Which side(s) of the body?
Left
Right
N/A
Date or approximate date of onset or injury
How did it happen?
Unknown
Accident
Fall
Exercise
Other
Surgery performed?
Yes
No
Date and description of surgery
Have you had this problem before?
Yes
No
I don't know
Other
What did you do for the problem?
Physical therapy
Medication
Other practitioner
Self-treatment
Other
Did the problem get better?
Yes
No
I don't know
N/A
Have you had any tests for your current problem? Eg: MRI, x-ray, lab work
Are you seeing anyone else for the problem?
Acupuncturist
Cardiologist
Chiropractor
Massage therapist
Obstetrician / gynecologist
Orthopedist
Podiatrist
Primary care physician
Psychologist / therapist
Physiatrist
Rheumatologist
Other physician
Other
Please list three activities that are difficult for you right now because of your problem
Do you ever have pain with this problem?
Yes
No
If 0/10 is no pain and 10/10 is the worst imaginable pain, what is your pain level right now?
Please Select
0/10
1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
10/10
Not sure
What is your pain level at its worst?
Please Select
0/10
1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
10/10
Not sure
What is your pain level at its best?
Please Select
0/10
1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
10/10
Not sure
Please tell us anything else that will help us understand your problem.
Submit
Should be Empty: