|
Reason For Visit
|
What is your Chief Complaint:
|
|
When and how did symptoms start?
|
What activities are painful and/or limited?
|
|
Worst pain within the past week (intensity)
|
Pain level right now
|
|
Rate your percentage from normal, 100% is ideal. Consider pain and function.
• • •
|
|
|
History
|
|
|
Major Surgical History?
|
If yes, list surgeries:
|
|
Prior Related Injuries or Conditions?
|
If yes, list:
|
|
Taking Medication or Supplements?
|
If yes, list:
|
|
Any medication allergies?
|
If yes, list medication allergies:
|
|
Any medical conditions?
|
List:
|
|
Smoke?
|
Marital status:
|
|
Work Status:
|
Occupation:
|
|
Exercise?
• • •
|
Type of exercise/training?
|
|
Name of Primary Care Physician:
|
Experiencing any of the following?
• • •
|
