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Please detail each region of your Chief Complaints for medical record
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Neck pain
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Are you experiencing Neck pain?
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Neck pain
• • •
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Type of pain
• • •
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Change in pain
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Average neck pain
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Pain at its worst
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Radiating
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Pain into the Arm?
• • •
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Numbness/ Tingling
• • •
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How Frequent is your Neck pain?
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What time of day is pain worse?
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What provokes neck pain?
• • •
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Additional Comments:
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What time of day is pain least?
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What relieves pain?
• • •
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Additional Comments:
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Medications for injuries:
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Are you experiencing headaches?
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Headache location
• • •
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Concussion and PTSD symptoms
• • •
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Headache comments
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Neck Disability Index
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Neck Disability Index
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This questionnaire has been designed to give us information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and select in each section only the one option that applies to you.
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Section 1: Pain Intensity
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Section 2: Personal Care (Washing, Dressing, etc.)
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Section 3: Lifting
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Section 4: Reading
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Section 5: Headaches
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Section 6: Concentration
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Section 7: Work
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Section 8: Driving
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Section 9: Sleeping
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Section 10: Recreation
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Low Back
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Are you experiencing Back pain?
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Back pain
• • •
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Type of back pain
• • •
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Change in pain
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Average back pain
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Pain at its worst
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Radiating
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Pain into the Leg?
• • •
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Numbness/ Tingling
• • •
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How Frequent is your Low back pain?
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What provokes Low back pain?
• • •
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Additional Comments:
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What relieves pain?
• • •
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Additional Comments:
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What time of day is pain least?
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What time of day is pain worse?
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Medications for injuries:
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Oswestry Disability Index
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Oswestry Disability Index
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This questionnaire has been designed to give us information as to how your back pain has affected your ability to manage in ever
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Section 1: Pain Intensity
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Section 2: Personal Care (Washing, Dressing, etc.)
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Section 3: Lifting
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Section 4—Walking
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Section 5—Sitting
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Section 6—Standing
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Section 7—Sleeping
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Section 8—Sex life (if applicable)
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Section 9—Social life
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Section 10—Travelling
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Do you have Upper Extremity Injury?
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Upper extremity pain?
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Upper Extremity
• • •
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Type of pain
• • •
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Change in pain
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Average upper extremity pain
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Pain at its worst
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How Frequent is your Upper extremity pain?
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What time of day is pain worse?
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What provokes upper extremity pain?
• • •
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What time of day is pain least?
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What relieves pain?
• • •
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Do you have Lower Extremity injury?
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Lower extremity pain?
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Lower Extremity
• • •
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Type of pain
• • •
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Change in pain
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Average Lower extremity pain
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Pain at its worst
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How Frequent is your pain?
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What time of day is pain worse?
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What provokes extremity pain?
• • •
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What time of day is pain least?
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What relieves pain?
• • •
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Functional Loss
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Please write a detail of how your injuries affect your life
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How has the injury affected you Work Life?
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How has the injury affected your Social Life?
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How has the injury affected your Personal Life?
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Medical History
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Medical History
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Past Medical History
• • •
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Any other significant Medical History?
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Past Surgical History
• • •
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Past Spinal or Orthopedic Surgeries
• • •
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Comments regarding surgeries
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Primary care doctor?
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Comments
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Allergies
• • •
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Disclose Allergies
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Social History
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Social History
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Marital Status
• • •
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Occupation
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Do you have Children?
• • •
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Comments
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Medical history
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