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Thinking about the LAST TWO WEEKS, tick your response to the following questions:
1. My back pain has SPREAD DOWN MY LEG(S) at some time in the last 2 weeks.
2. I have had pain in the SHOULDER OR NECK at some time in the last 2 weeks.
3. I have only WALKED SHORT DISTANCES because of my back pain.
4. In the last 2 weeks, I have DRESSED MORE SLOWLY than usual because of my back pain.
5. It's not really safe for a person with a condition like mine to be physically active.
6. WORRYING THOUGHTS have been going through my mind a lot of the time.
7. I feel that MY BACK PAIN IS TERRIBLE and IT'S NEVER GOING TO GET ANY BETTER.
8. In general I have NOT ENJOYED all the things I used to enjoy.
9. Overall, how BOTHERSOME has your back pain been in the LAST 2 WEEKS?

The Keele STarT Back Screening Tool (United Healthcare Patient Summary) Medical Form

Chiropractor

United Healthcare requires this with their "Patient Summary" that must be filled out online the date of service.

There are 0 copies in use.
Published: Feb. 12, 2019, 1:37 p.m.
Doctor: Dr. History Physical
Rating: 0   /

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