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Height / Weight
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Hand Dominance
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What is your primary complaint?
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Rate your current pain on a 0-10 scale:
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Describe the type of pain you're experiencing.
• • •
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Describe how your pain began.
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Rate your pain at its worst on a 0-10 scale:
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How long have you been in pain?
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Approx date of injury/onset of pain (mm/dd/yyyy)
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What makes your pain worse?
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How often do you experience this type of pain?
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Have you experienced similar pain before?
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What makes your pain better?
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Have you been treated for this complaint before?
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If "Yes", when did you experience similar pain?
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What does this pain prevent you from doing?
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If "Yes", by whom? (name/location)
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Is this complaint related to an auto accident?
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If female, are you pregnant?
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PAST MEDICAL HISTORY
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Has a worker's comp claim been filed for this?
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Do you have any ongoing medical conditions?
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Do you have a history of any medical conditions?
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If "YES", please list here:
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Have you recently been hospitalized?
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If "YES", please list here:
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Have you fallen & been injured in the past year?
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Have you had a physical in the past year?
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PAST SURGICAL HISTORY
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Have you fallen 2+ times in the past year?
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Have you had any major surgeries?
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FAMILY MEDICAL HISTORY
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If "YES", please list here:
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Father's medical history:
• • •
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Mother's medical history:
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If "OTHER", please list here:
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Sibling medical history:
• • •
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If "OTHER", please list here:
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SOCIAL HISTORY
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If "OTHER", please list here:
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How often do you consume alcohol?
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Do you smoke?
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How often do you consume caffeine?
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Are you currently employed?
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If "Yes", approximately how many packs per day?
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List any leisurely or recreational activities:
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If "Yes", what is your occupation?
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CURRENT MEDICATIONS
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If a runner, how many miles per week do you run?
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Please list any current medications:
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ALLERGIES
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Please list any allergies:
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