OPTUM Page 1

OPTUM Page 1

This is a required form for United Healthcare Patients only.
Name *

First Name Last Name
Date Symptoms Began *

Month Day Year
Please give an estimated date if you do not have exact.
Briefly Describe your Symptoms: *
How did your Symptoms start: *
Average Pain Intensity: *
Average Pain in last 24 hours
Average Pain Intensity: *
Average pain over the last week.
How often do you experience your symptoms: *

Constantly (76%-100% of the time) Frequently (51%-75% of the time) Occasionally (26%-50% of the time) Intermittently (0%-25% of the time)
How much have your symptoms interfered with daily activity: *

Not at all A little bit Moderatley Quite a bit Extremely
How is your condition changing since care began at this facility *

N/A - This is initial visit Much worse Worse A little worse No change A little better Better Much better
In general, would you say your overall health is : *

Excellent Very Good Good Fair Poor
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: