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Patient Name:
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Date of Visit:
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Patient Areas of Complaint: (Please check all that apply)
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Date of injury/Accident:
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How did this injury occur?
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Please describe in your own words what happened during the injury:
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Auto Accident: (Please list all that apply to your accident)
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Following your injury, when did you first seek medical treatment?
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Location of pain #1:
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Using a scale of 1-10, 1 being very little pain and 10 horrible pain. What is your pain on a good day?
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Using a scale of 1-10, 1 being very little pain and 10 horrible pain. What is your pain on a bad day?
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Describe your pain. (Please list all that apply)
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How often do you have this pain?
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What makes the pain better?
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What makes the pain worse?
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Since the onset of this injury, the pain has become
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As a result of this pain do you experience:
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If so, please explain:
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Location of pain #2:
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Using a scale of 1-10, 1 being very little pain and 10 horrible pain. What is your pain on a good day?
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Using a scale of 1-10, 1 being very little pain and 10 horrible pain. What is your pain on a bad day?
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Describe your pain. (Please list all that apply)
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How often do you have this pain?
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What makes the pain better?
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What makes the pain worse?
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Since the onset of this injury, the pain has become
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As a result of this pain do you experience:
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If so, please explain:
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Location of pain #3:
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Using a scale of 1-10, 1 being very little pain and 10 horrible pain. What is your pain on a good day?
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Using a scale of 1-10, 1 being very little pain and 10 horrible pain. What is your pain on a bad day?
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Describe your pain. (Please list all that apply)
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How often do you have this pain?
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What makes the pain better?
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What makes the pain worse?
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Since the onset of this injury, the pain has become
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As a result of this pain do you experience:
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If so, please explain:
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Medications I take for the pain are:
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Does the medication help?
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Are you now or have you ever had therapy for this injury?
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Was therapy helpful?
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What type of therapy have you had?
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What type of injections have you tried previously?
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How long did you get relief?
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Have you ever had surgery for this injury?
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If you have had surgery for this injury, what type and when?
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Have you ever injured the same area before?
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Were you fully recovered from that injury before this one occurred?
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Are you working currently since the injury has occurred?
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What is your occupation?
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Have you missed work due to your injury?
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If you have missed work due to your injury, how long have you missed?
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Please select all ofthe following that apply to you.) General medical history:
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Patient consent to treat and attestation
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