"*" indicates required fields Patient Name*DOB* MM slash DD slash YYYY InstructionsChoose pain / sensations from each dropdown as needed.Choose Location of Pain or Sensation (FRONT)*NoneLeft Arm / HandRight Arm / HandLeft Leg / FootRight Leg / FootAbdomenGroinUpper Left ChestUpper Right ChestNeckHeadChoose Location of Pain or Sensation (BACK)*NoneLeft Arm / HandRight Arm / HandLeft Leg / FootRight Leg / FootLower BackUpper Left BackUpper Right BackNeckHeadPain Scale (FRONT)*0 (No Pain)12345678910 (Worst Possible Pain)Pain Scale (BACK)*0 (No Pain)12345678910 (Worst Possible Pain)1. What activities make your pain worse? Please check ALL that apply to you.* Lying Standing Sitting Walking Exercise (during) Exercise (after) Bending Forward Bending Backward Twisting Coughing/Sneezing 2. What reduces your pain? Please check ALL that apply to you.* Lying Standing Sitting Walking Exercise (during) Exercise (after) Bending Forward Bending Backward Twisting Coughing/Sneezing 3. What medication and dosage either prescriptions or over the counter are you currently taking for this pain?NONE None 4. Are you currently under treatment at a Pain Center?* Yes No If so, where?5. Are you currently under a pain contract with anyone?* Yes No If so, where and length of time?6. What treatments have you tried for this pain?* Physical Therapy Chiropractic Acupuncture Home Exercises None 7. Have you been seen for this current pain by:* MD/NP/PA Urgent Care Center Emergency Room Hospitalized None If so, date of visit?PhoneThis field is for validation purposes and should be left unchanged.
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