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Have you ever had any of the following?
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Do you have?
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Frequent low basal body auxiliary temperature
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Do you have problems with constipation?
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Do you have ?
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Any unexplained arthritis in various joints?
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Do you have lot of mucus in your stools?
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Unidentified chest pains.
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Do you have?
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Patients Kidney problems:
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Are you extremely fatigued much of the time?
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Irritability or dramatic changes in behavior?
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Any antidepressants?
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Orthopedic Health
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Locate the areas of pain (Front)
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Pain Level:
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Locate the areas of pain (Back)
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Pain Level:
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Date of Injury
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How did you get hurt?
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Has this been a problem before?
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If YES, please explain:
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Character of your pain
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Continuous (all day):
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Explain Where?
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Intermittent (on & off):
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Explain Where?
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Occasionally:
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Explain Where?
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What makes your pain worse?
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How long can you currently:
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What makes your pain better?
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Other
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Does pain limits your activities of daily living
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If YES, what percent of the day:
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Self care:
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Physical Activity:
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Hand Activity:
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Travel:
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Sexual Function:
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Does the pain interrupts your daily exercise?
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If YES, please explain:
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Does the pain affect your sleep?
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If YES, please explain:
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Treatments that you had?
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Please mention the date of the treatment:
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Was the treatments helpful?
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If NO, please explain:
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