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Why are you here today? Please complete every field in this tab.
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Date of Onset or Accident
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Onset Description (Please be descriptive)
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Area(s) of Complaint
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Rate the area of pain from 1-10
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Chronology of the pain
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Radiating pain
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Describe the areas of pain.
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What makes the pain better?
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What makes the pain worse?
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Any other comments?
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Have you been treated elsewhere for this condition
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which facility did you go to?
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If you sought care, was any imaging done?
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Imaging Type
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Were you involved in an Auto Accident or at Work? If so, turn on the appropriate incident.
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Recent Auto Accident?
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Recent On the Job Injury
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Please describe in as much detail as possible what happened during this collision.
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What’s the last thing you remember before the accident?
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What was the first thing you remember after the accident?
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Where were you in the vehicle?
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How many people were in the accident vehicle?
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Road/Street Name
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City and State
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Make and model of other vehicle?
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Describe the damage to the other vehicle.
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Make and Model of vehicle you were in?
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Describe the damage to your vehicle
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Did your vehicle hit any structures?
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Was your car pushed out of position from the impact?
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Was your car stopped at the time of impact?
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If your car was moving at the time of impact was it:
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Where was your vehicle struck
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Did you brace for impact?
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Were you wearing a seat belt?
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Did your seat have a head rest?
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Was your vehicle equipped with airbags?
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If yes did they properly inflate?
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Was there inside damage to the vehicle?
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Did any part of your body strike anything?
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At the time of impact where were you looking?
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Driving Conditions
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Did the police come to the accident?
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Was a traffic violation issued?
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Were you deemed the at fault party?
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Have you told your insurance company?
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If you have an attorney, who is it?
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Did you report the injury to your boss?
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How is your employer insured?
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Have you filed a claim already?
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If you have an attorney, who is it?
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Questionnaires (The Doctor or Staff will ask you to fill these out if needed).
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Patient Progress Re-Evaluation
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Color in the areas you are still having pain.
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Please explain what improvements you have noticed since beginning care with our office.
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Please explain changes since last re-exam. (If this is first re-exam skip this question)
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What conditions have not improved?
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Neck Pain Disability Index
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PAIN INTENSITY
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PERSONAL CARE
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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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Score:
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Score Defined
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Oswestry Back Questionnaire
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PAIN INTENSITY
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PERSONAL CARE (e.g. Washing, Dressing)
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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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SOCIAL LIFE
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TRAVELING
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EMPLOYMENT/ HOMEMAKING
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Score:
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Score Defined
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Neuropathic Pain Scale
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Does your pain feel like burning?
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Does your pain feel like squeezing?
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Does your pain feel like pressure?
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How often has the pain been present?
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Does your pain feel like electric shock?
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Does your pain feel like stabbing?
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During the past 24 hours how many attacks have you had?
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Is the pain provoked by brushing the painful area?
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Is your pain provoked by pressure on the painful area?
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Is your pain provoked by cold on the injured area?
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Do you feel pins and needles?
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Do you feel tingling?
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Thoracic Outlet Syndrome Questionnaire
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Do you have head (headaches) pain?
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Front or Back of Head
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Do you have neck pain?
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Left, Right or both
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Do you have pain between the shoulders?
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Left, Right or both
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Do you have pain in your shoulder joint(s)?
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Left, Right or both
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Do you have pain in your arm above the elbow?
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Left, Right or both
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Do you have pain in your elbow?
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Left, Right or both
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Do you have pain in your forearm?
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Left, Right or both
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Do you have pain in your hand?
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Left, Right or both
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Do you have numbness or tingling in your fingers?
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If yes, which fingers?
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Do you have numbness or tingling in your forearm?
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Left, Right or both
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Do you have numbness or tingling in your arm?
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Left, Right or both
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Do you have weakness in your arm or hand?
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Left, Right or both
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Does elevating your hand make it worse?
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Left, Right or both
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Were you in an accident?
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If from an accident what was the date?
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Were any of your arm symptoms present before the accident?
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Have you had prior head or neck accidents prior to this one?
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Head Injury Questionnaire
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Did your head hit any part of the car?
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What part of your head was hit?
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What was the last thing you remember before the collision?
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What was the very next thing you remember after the collision?
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After the collision did you feel dazed or confused?
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Have you lost any memory of anything before the collision?
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Has your memory been different since the head injury?
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Did you sustain a lump or bruise on your head?
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Have you had any head injuries in your past?
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Have you had any advanced imaging (ie. CT or MRI) of your head?
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Check symptoms you've had corresponding to your neck or head injury?
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