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Here with parent?
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What brings you here today?
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Is there anything else?
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Any other details?
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Share all my health information with:
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Do you have pain?
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Frequency
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For how long, this episode?
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Location of worst pain?
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Pain Quality
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Out of 10, pain level is usually:
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Pain increases with
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Pain decreases with
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Status?
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Mark up your pain
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Percentage improved
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Massage preferences
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Ever had a massage before?
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Table heat
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Pressure
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Goals
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Areas to avoid touching?
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Areas to avoid moving?
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Any special requests?
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Any product sensitivites?
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Are you pregnant?
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How many weeks?
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Current lesions, rashes, skin conditions?
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Explain
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Here for Massage Only? Stop Here
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Functional Movement Therapy
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Has your doctor ever said that you have a heart condition?
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AND that you should only do physical activity recommended by a doctor?
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Do you feel pain in your chest when you do physical activity?
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In the past month, have you had chest pain when you were not doing physical activity?
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Do you lose your balance because of dizziness or do you ever lose consciousness?
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Do you have a bone or joint problem that could be made worse by physical activity?
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Have you been prescribed medication for your blood pressure or heart condition?
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Do you know of ANY OTHER REASON why you should not do physical activity?
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Acupuncture Details
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Had acupuncture/dry needling before?
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How was your experience?
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Fear of needles?
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Do you have fatigue?
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Out of 10, if 10 is most fatigued:
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Daily Bowel Movement?
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Bowel movements per day?
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If not daily, BM per week?
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Sinus Congestion
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If so, describe mucus
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Runny Nose/Allergies
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If so, describe mucus
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Cough
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If so, describe mucus
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Additional symptoms
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Anything else we should know about?
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Keele STarT Back Form. PSCS only. In the last 2 weeks have you experienced?
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Back pain spread into my leg(s)
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Pain in the shoulder or neck
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Walked only short distances due to pain
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Dressed more slowly
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It's not really safe for a person with a condition like mine to be physically active.
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Worrying thoughts have been going through my mind a lot of the time.
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I feel that my back pain is terrible and it's never going to get any better.
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In general, I have not enjoyed all the things I used to enjoy.
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Overall, how bothersome has your back pain felt in the last 2 weeks?
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Low Back or Leg Pain
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Pain intensity
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Personal care (washing, dressing, etc)
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Lifting
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Walking
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Sitting
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Standing
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Sleeping
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Sex life (if applicable)
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Social life
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Traveling
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Neck Pain
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Pain Intensity
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Personal Care (Washing, Dressing, etc)
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Lifting
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Reading
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Headaches
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Concentration
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Work
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Driving
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Sleeping
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Recreation
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How has PAIN affected you life in general, lately?
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Family responsibilities: yard work, chores, driving kids to school
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Recreation: hobbies, sports, leisure activities
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Social Activity: parties, theater, dining out
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Occupation: job, volunteering, house chores
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Sexual Behavior: frequency and quality
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Self Care: showering, dressing, etc
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Life Supporting: eating, sleeping, etc
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In the past 24 hrs, how has PAIN affected your:
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Activity
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Sleep
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Mood
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Stress
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Headaches (HA) & migraines
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HA frequency
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HA severity
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Because of my headaches...
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I feel handicapped
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I feel desperate
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I restrict my recreational activities
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I am unable to think clearly.
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Sometimes I feel I'll lose control
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I am less likely to socialize
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My muscles get tense
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I do not enjoy social gatherings
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I feel irritable
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I avoid travelling
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I find it difficult to read
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I feel restricted in performing my routine daily activities
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I am concerned I am paying penalties at home & at work
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My significant other, family & friends have no idea what I am going through
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My HA place stress on my relationships with family or friends
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My HA are so bad, that I feel that I'm going to go insane
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No one understands the effect that HA have on my life
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My outlook on the world is affected by my HA
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I am afraid to go outside when I feel a HA coming on
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I avoid being around people when I have a HA
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I believe my HAs are making it difficult for me to achieve my goals in life
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I find it difficult to focus my attention away from my HA and on to other things
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My HA make me angry
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My HA make me feel confused
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My HAs make me feel frustrated
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Sleep: In the past month...
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When have you usually gone to bed?
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How long (min) does it take you to fall asleep?
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What time have you usually gotten up in the morning?
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How many hours of actual sleep did you get at night?
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How many hours were you in bed?
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Cannot go to bed within 30 minutes
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Wake up in the night or early in the morning
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Have to get up to use the bathroom
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Cannot breath comfortably
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You cough or snore loudly
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Feel too cold
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Feel too hot
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Have bad dreams
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Have pain
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What are other reasons you have trouble sleeping?
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In the past month, have you taken an OTC or prescription sleep aid?
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Have you had trouble staying awake while driving, eating meals, or socializing?
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In the past month, how hard has it been to keep up enthusiasm to get things done?
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In the past month, how would you rate your sleep quality overall?
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Tinnitus
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Does tinnitus make it difficult for you to concentrate?
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Does the loudness of your tinnitus make it difficult to hear people?
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Does your tinnitus make you angry?
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Does your tinnitus make you feel confused?
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Because of your tinnitus, do you feel desperate?
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Do you complain a great deal about your tinnitus?
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Because of your tinnitus, do you have difficulty falling asleep at night?
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Do you feel as though you cannot escape your tinnitus?
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Does tinnitus interfere with your ability to enjoy your social activities?
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Because of your tinnitus, do you feel frustrated?
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Because of your tinnitus, do you feel you have a terrible disease?
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Does tinnitus make it difficult for you to enjoy life?
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Does tinnitus interfere with your job or household responsibilities?
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Because of your tinnitus, do you find that you are often irritable?
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Because of your tinnitus, is it difficult for you to read?
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Does your tinnitus make you upset?
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Does tinnitus put stress on your relationships?
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Is it difficult to focus on things other than your tinnitus?
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Do you feel that you have no control over your tinnitus?
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Because of your tinnitus, do you often feel tired?
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Because of your tinnitus, do you feel depressed?
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Does your tinnitus make you feel anxious?
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Do you feel that you can no longer cope with your tinnitus?
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Does your tinnitus get worse when you're under stress?
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Does your tinnitus make you feel insecure?
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EviCore. What is your level of function? 0 = no function & 10 = perfect function
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Functional movement
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Score
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Functional movement
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Score
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Functional movement
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Score
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Functional movement
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Score
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Functional movement
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Score
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