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ADDITIONAL PATIENT INTAKE
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NEW PATIENT ADDITIONAL HISTORY
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What type of complaint?
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Where is your complaint?
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How is your primary complaint doing?
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Rate your pain (1-10)
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How did your injury occur?
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When did your condition begin?
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What is the frequency of your pain?
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What is the quality of your discomfort?
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What makes your condition better?
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What makes your condition worse?
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If discomfort radiates, where does it radiate?
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Have you had this injury / condition before?
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Past treatments received for this complaint?
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Have you had recent diagnostic imaging or tests?
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Which activity of daily living is most affected?
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Which activities do you have difficulty with?
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What musculoskeletal issues do you have?
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What neurological conditions do you have?
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Surgical History? (If yes, please list)
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Drugs & Medications? (Please list)
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Name Past Illnesses:
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Past history of accident or trauma?
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Immediate Family Health History? (Please list)
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Social Habits?
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Exercise Frequency?
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Type of Exercise?
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Describe your diet?
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WOMEN ONLY
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Are you pregnant?
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Are you nursing?
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Are you taking birth control?
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Do you experience painful periods?
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Do you have irregular cycles?
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Do you have breast implants?
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Do you have regular breast exams?
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Do you take HRT?
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Do you take oral contraceptives?
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Date of last PAP / Pelvic Exam?
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Date of last mammogram?
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Date of LMP?
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MEN ONLY
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Pain or Lump in Scrotum
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Impaired Libido
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Penile Discharge
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Prostate Issues
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Last Prostate Exam (Date)
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Last PSA Test (Date)
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LOW BACK PAIN
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Pain Intensity
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Personal Care
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Sleeping
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Lifting
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Sitting
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Traveling
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Standing
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Social Life
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Walking
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Changing degree of pain
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Initial Back Pain Index (Office Use Only)
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Current Back Pain Index (Clinic Use Only)
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NECK PAIN
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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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Initial Neck Pain Index (Office Use Only)
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Current Neck Pain Index (Office Use Only)
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UPPER EXTREMITY
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Open a tight jar
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Writing
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Turning a key
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Preparing a meal
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Push open a heavy door
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Place objects on a shelf above your head
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Perform heavy household chores
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Doing yard work or garden
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Making a bed
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Carrying a shopping bag or briefcase
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Carry a 10lb object
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Change a lightbulb overhead
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Wash or blow dry your hair
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Wash your back
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Putting on a sweater
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Use a knife to cut food
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Playing cards or knitting
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Sporting activities
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Driving a car
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Are you limited in social activities
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Are you limited in daily activities
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Upper extremity pain
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Upper extremity pain during specific activity
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Tingling (pins / needles) in upper extremity
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Weakness in upper extremity
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Stiffness in upper extremity
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Difficulty sleeping in past week
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Less confident or useful due to injury
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DASH Disability Score (Office Use Only)
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LOWER EXTREMITY
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Ability to do regular daily activities
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Ability to do hobbies or sports
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Getting in and out of bed
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Walking between rooms
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Putting on shoes and socks
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Squatting
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Lifting object off the floor
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Performing light household activities
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Performing heavy household activities
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Getting in and out of car
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Walking 2 blocks
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Walking a mile
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Going up or down 10 stairs (1 flight)
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Standing for 1 hour
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Sitting for 1 hour
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Running on even ground
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Running on uneven ground
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Making sharp turns while running fast
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Hopping / Jumping
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Rolling over in bed
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LEFS Score (Office Use Only)
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