germantownchiro.com - RE-EXAMINATION FORM

RE-EXAMINATION FORM
Name:
Date:

MonthDayYear
Date
Have you had any new injuries/surgeries/other changes since your last visit?

NoneYes
Explain Yes:
I am here for a:

New ComplaintExisting Complaint
Describe Complaint:
My current complaint of _________________________ is Better Worse Unchanged
If better, what percentage improvement have you noted since starting treatment?
%
My other complaint of _________________________ is Better Worse Unchanged
If better, what percentage improvement have you noted since starting treatment?
%
How are things better/worse/same? (I can do more activities, intensity is less, frequency is less, etc.)
Please mark the areas of pain:
Please rate your pain on a scale of 0-10 with a 0 being no pain at all and a 10 being the worst pain you have ever had in your life:

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Worst Pain
What frequency do you experience pain? Type here % of the (select one) Day Week Month
Have you had any other treatment for this since your last patient visit?:

NoneYes
Explain Yes
What makes it better?

IceRestMovementStretchingMedicationOther
What makes it worse?

StandingSittingWalkingBendingWorkingOther
Quality of Pain:

SharpDullAchingBurningStiffTinglingNumbStabbingOther
Other important changes/information?
Patient Signature

Clear
Date

MonthDayYear
Date
Should be Empty: