|
History of Presenting Complaint(s)
|
|
|
Primary Complaint
|
|
|
What is your primary complaint?
|
|
|
How did this occur?
|
When did your symptoms begin?
|
|
Are you experiencing any of the following?
• • •
|
Please indicate area(s) of complaint
|
|
Intensity of chief complaint:
• • •
|
Frequency of symptoms?
• • •
|
|
Have you ever experienced this before?
|
If yes, when?
|
|
Have you been treated for this before?
|
If yes, by whom?
• • •
|
|
Are you still receiving treatment from another provider?
|
Are these symptoms related to an auto accident?
|
|
Secondary Complaint
|
|
|
What is your secondary complaint?
|
|
|
How did this occur?
|
When did your symptoms begin?
|
|
Intensity of secondary complaint:
• • •
|
Frequency of symptoms?
• • •
|
|
Have you ever experienced this before?
|
If yes, when?
|
|
Have you been treated for this before?
|
If yes, by whom?
• • •
|
|
Are you still receiving treatment from another provider?
|
Are these symptoms related to an auto accident?
|
|
Goals/Outcomes
|
|
|
What do these symptoms prevent you from doing?
|
Describe your Goal(s) for Treatment:
|
