Date:

Patient Name:

Referring Physician:

Primary Diagnosis:

HISTORY:

Age:_____                                                       Sex:_____

Dominance: R \ L                                              Occupation:__________________________

Recreation/Hobbies:_______________________________________________________________________________________________________________________________________________________________________________________________________

Past Medical History:______________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medications:_____________________________________________________________

RELEVANT HISTORY:

Where is the site of your injury or pain ? _______________________________________

________________________________________________________________________________________________________________________________________________

How and When did you injure yourself or begin to notice symptoms?________________

________________________________________________________________________________________________________________________________________________

How would you describe the nature of your pain? Circle those that apply: sharp· dull· stabbing · aching · burning · shooting · throbbing · cramping · nagging · tingling

Does your pain radiate?____________________________________________________

Using the following intensity scale:

0          1          2          3          4          5          6          7          8          9          10

No pain         Discomfort            Moderate Pain              Severe pain                Unbearable

Rate your pain at the time of this evaluation_____   and at its worst_____

Circle those that apply:  Is your pain constant? Intermittent?  Brief?  Fluctuating?

Have your symptoms increased, decreased, or remained the same for the last 30 days?___

________________________________________________________________________

Are there any activities that INCREASE your symptoms?_________________________

________________________________________________________________________

Are there any activities that DECREASE your symptoms?_________________________

________________________________________________________________________

Are there any postures or positions that INCREASE your symptoms?________________

________________________________________________________________________

Are there any postures or positions the DECREASE your symptoms?________________

________________________________________________________________________

Are you experiencing any functional limitations presently?(i.e. difficulty dressing, grooming, eating, performing household chores, performing occupational tasks)________ ________________________________________________________________________________________________________________________________________________

Are you experiencing any buckling or instability?________________________________

Have you experienced these symptoms before? If yes, did you receive treatment? What was the outcome of that treatment?___________________________________________

_______________________________________________________________________

Are you currently taking any medication for this specific complaint?_________________

________________________________________________________________________

Have you had any of the following diagnostic tests for these symptoms? X-ray? MRI? CT Scan? Other?…If yes do you have the results?__________________________________

________________________________________________________________________________________________________________________________________________