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- Confidential Patient Information -
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1. Mark an (X) where you have pain/symptoms (iPad Only)
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2. Select your current complaints:
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Other:
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3. What are your symptoms due to?
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4. What is your level of pain today? (0 = No Pain, 10 = Unbearable pain)
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5. How would you describe your pain?
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Other:
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6. What movements aggravate your pain?
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Other:
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7. How often are your symptoms present?
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8. Is your pain getting:
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9. In the last week, how much has your pain interfered with your daily activities? (e.g. work, social activities, etc)
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10. Who else have you seen for this condition?
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Other:
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11. Date problem/condition began?
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12. How problem/condition began?
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13. Your overall health in general right now?
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14. Have you had X-rays, MRI, or CT-scan of problem area?
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If yes, Date & which area scanned?
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15. Please select all of the following that apply to you:
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Other Health Problems - Please Explain:
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Stroke (Date of occurrence)
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Cancer/Tumor (Explain):
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Current Pregnancy # of Weeks
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Abnormal Weight
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Tobacco Use (Type & Frequency(per Day))
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Medications:
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16. Family History
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Authorization & Acknowledgement (iPad Only)
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