Date:
Patient Name:
Referring Physician:
Primary Diagnosis:
HISTORY:
Age:_____ Sex:_____
Dominance: R \ L Occupation:__________________________
Recreation/Hobbies:_______________________________________________________________________________________________________________________________________________________________________________________________________
Past Medical History:______________________________________________________
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Medications:_____________________________________________________________
RELEVANT HISTORY:
Where is the site of your injury or pain ? _______________________________________
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How and When did you injure yourself or begin to notice symptoms?________________
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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?___
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Are there any activities that INCREASE your symptoms?_________________________
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Are there any activities that DECREASE your symptoms?_________________________
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Are there any postures or positions that INCREASE your symptoms?________________
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Are there any postures or positions the DECREASE your symptoms?________________
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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?___________________________________________
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Are you currently taking any medication for this specific complaint?_________________
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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?__________________________________
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