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Are You Here for Wellness/Prevention i.e., NO INSURANCE WILL BE BILLED
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If Yes, Check the YES Box Below and Hand IPad Back To Receptionist
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If No, Check the NO box below, Read Instructions Below, Then Scroll Down to Symptoms 1-5 & Answer ALL Applicable Questions
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Wellness/Prevention Visit?
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Below you will find various drop down menus and boxes for 5 body areas, there are 17 questions for each area of complaint.
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Please be thoughtful and deliberate when answering each question. When finished, click "Finish Check-In".
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This Box is for Doctor Use Only
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This Box is For Doctor Use Only: Cauda Equina?
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This Box is For Doctor Use Only: Concussion?
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Symptom 1
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1. What is Your Most Prominent Symptom?
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2. What Part of Your Body is Affected?
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3. What Side Is It On?
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4. What Does it Feel Like?
• • •
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5. Intensity: 0=No Pain 10= Worst Pain Imaginable; Bed Rest Required, Moaning, Writhing & Crying Out Present
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6. Does Any Symptom Radiate From The Part of Your Body Listed Above, to Another Part of Your Body?
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7. If Yes, Where does it radiate to? (Body Part)
• • •
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8. Which Side (L/R) Upper/Lower
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9.What Percentage of the Time is This Symptom Present?
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10.What Makes This Symptom Worse?
• • •
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Other Factor(s) that Worsen Your Condition
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11. What Makes This Symptom Better?
• • •
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Other Factor(s) that Improve Your Condition
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12. What Caused or Brought on This Symptom?
• • •
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Other Mechanism of Injury or Causative Factor
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13. When Did This Symptom Begin?
• • •
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Date of Occurrence MM/DD/YYYY
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14. Activity Interference 0=Does not Interfere with Activities, 10= Completely Prevents Activities
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15. List ALL Activities THIS PAIN Interferes With
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16. Prior Treatment Received for This Condition
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DO NOT COMPLETE # 17 IF THIS IS YOUR FIRST VISIT
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17. Percentage of Change Since First Visit
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Patient Remarks
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Please Use The Boxes Below to Describe Your Symptoms
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Symptom 2
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1. What is Your Second Most Prominent Symptom?
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2. What Part of Your Body is Affected?
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3. What Side Is It On?
• • •
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4. What Does it Feel Like?
• • •
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5. Intensity: 0=No Pain 10= Worst Pain Imaginable; Bed Rest Required, Moaning, Writhing & Crying Out Present
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6. Does Any Symptom Radiate From The Part of Your Body Listed Above, to Another Part of Your Body?
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7. If Yes, Where does it radiate to? (Body Part)
• • •
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8. Which Side (L/R) Upper/Lower
• • •
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9.What Percentage of the Time is This Symptom Present?
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10.What Makes This Symptom Worse?
• • •
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Other Factor(s) that Worsen Your Condition
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11. What Makes This Symptom Better?
• • •
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Other Factor(s) that Improve Your Condition
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12. What Caused or Brought on This Symptom?
• • •
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Other Mechanism of Injury or Causative Factor
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13. When Did This Symptom Begin?
• • •
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Date of Occurrence MM/DD/YYYY
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14. Activity Interference 0=Does not Interfere with Activities, 10= Completely Prevents Activities
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15. List ALL Activities THIS PAIN Interferes With
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16. Prior Treatment Received for This Condition
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DO NOT COMPLETE #17 IF THIS IS YOUR FIRST VISIT
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17. Percentage of Change Since First Visit
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Patient Remarks
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Symptom 3
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1. What is Your Third Most Prominent Symptom?
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2. What Part of Your Body is Affected?
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3. What Side Is It On?
• • •
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4. What Does it Feel Like?
• • •
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5. Intensity: 0=No Pain 10= Worst Pain Imaginable; Bed Rest Required, Moaning, Writhing & Crying Out Present
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6. Does Any Symptom Radiate From The Part of Your Body Listed Above, to Another Part of Your Body?
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7. If Yes, Where does it radiate to? (Body Part)
• • •
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8. Which Side (L/R) Upper/Lower
• • •
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9.What Percentage of the Time is This Symptom Present?
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10.What Makes This Symptom Worse?
• • •
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Other Factor(s) that Worsen Your Condition
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11. What Makes This Symptom Better?
• • •
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Other Factor(s) that Improve Your Condition
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12. What Caused or Brought on This Symptom?
• • •
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Other Mechanism of Injury or Causative Factor
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13. When Did This Symptom Begin?
• • •
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Date of Occurrence MM/DD/YYYY
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14. Activity Interference 0=Does not Interfere with Activities, 10= Completely Prevents Activities
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15. List ALL Activities THIS PAIN Interferes With
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16. Prior Treatment Received for This Condition
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DO NOT COMPLETE #17 IF THIS IS YOUR FIRST VISIT
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17. Percentage of Change Since First Visit
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Patient Remarks
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Symptom 4
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1. What is Your Fourth Most Prominent Symptom?
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2. What Part of Your Body is Affected?
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3. What Side Is It On?
• • •
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4. What Does it Feel Like?
• • •
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5. Intensity: 0=No Pain 10= Worst Pain Imaginable; Bed Rest Required, Moaning, Writhing & Crying Out Present
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6. Does Any Symptom Radiate From The Part of Your Body Listed Above, to Another Part of Your Body?
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7. If Yes, Where does it radiate to? (Body Part)
• • •
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8. Which Side (L/R) Upper/Lower
• • •
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9.What Percentage of the Time is This Symptom Present?
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10.What Makes This Symptom Worse?
• • •
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Other Factor(s) that Worsen Your Condition
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11. What Makes This Symptom Better?
• • •
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Other Factor(s) that Improve Your Condition
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12. What Caused or Brought on This Symptom?
• • •
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13. When Did This Symptom Begin?
• • •
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Date of Occurrence MM/DD/YYYY
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14. Activity Interference 0=Does not Interfere with Activities, 10= Completely Prevents Activities
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15. List ALL Activities THIS PAIN Interferes With
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16. Prior Treatment Received for This Condition
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DO NOT COMPLETE # 17 IF THIS IS YOUR FIRST VISIT
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17. Percentage of Change Since First Visit
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Patient Remarks
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Symptom 5
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1. What is Your Fifth Most Prominent Symptom?
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2. What Part of Your Body is Affected?
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3. What Side Is It On?
• • •
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4. What Does it Feel Like?
• • •
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5. Intensity: 0=No Pain 10= Worst Pain Imaginable; Bed Rest Required, Moaning, Writhing & Crying Out Present
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6. Does Any Symptom Radiate From The Part of Your Body Listed Above, to Another Part of Your Body?
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7. If Yes, Where does it radiate to? (Body Part)
• • •
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8. Which Side (L/R) Upper/Lower
• • •
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9.What Percentage of the Time is This Symptom Present?
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10.What Makes This Symptom Worse?
• • •
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Other Factor(s) that Worsen Your Condition
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11. What Makes This Symptom Better?
• • •
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Other Factor(s) that Improve Your Condition
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12. What Caused or Brought on This Symptom?
• • •
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13. When Did This Symptom Begin?
• • •
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Date of Occurrence MM/DD/YYYY
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14. Activity Interference 0=Does not Interfere with Activities, 10= Completely Prevents Activities
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15. List ALL Activities THIS PAIN Interferes With
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16. Prior Treatment Received for This Condition
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DO NOT COMPLETE #17 IF THIS IS YOUR FIRST VISIT
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17. Percentage of Change Since First Visit
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Patient Remarks
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