Patient Information
Full name
*
Date of birth
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Date of service (DOS)
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1. Last Treatment
What treatment did you receive last time?
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Injection
Medication
Imaging (e.g., MRI, X-ray)
Physical Therapy
Chiropractic Treatment
Other
Select all that apply.
Other treatment (please specify) - required; type N/A if not applicable
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Date of last treatment (MM/DD/YYYY, or N/A if none; Unknown if you do not recall)
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How much improvement did you experience after the last treatment? (%)
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2. Duration of Improvement
Improvement lasted (weeks)
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Improvement lasted (months)
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3. How Your Pain Has Shifted
How has the pain shifted?
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Constant
Periodic
Where is your pain currently located?
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4. Frequency and Description of Pain
How often do you feel the pain?
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Constant
Comes and goes (intermittent)
How would you describe the pain?
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Sharp
Dull
Burning
Aching
Throbbing
Tingling
Stabbing
Numbness
Other
Select all that apply.
Other description (please specify) - required; type N/A if not applicable
*
5. Radiation of Pain
Does the pain spread or radiate to other areas?
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Yes
No
Yes - where does it radiate to? - required; type N/A if you answered No
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6. Pain Score (0 = no pain, 10 = worst pain imaginable)
At its best (/10)
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At its best (/10)
At its worst (/10)
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At its worst (/10)
7. What Makes the Pain Worse
What makes the pain worse?
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Walking
Standing for long periods
Sitting
Bending forward
Lifting
Twisting
Climbing stairs
Physical activity/exercise
Lying down
Weather changes
Stress
Other
Select all that apply.
Other aggravator (please specify) - required; type N/A if not applicable
*
8. What Helps Relieve the Pain
What helps relieve the pain?
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Rest
Ice
Heat
Stretching
Over-the-counter medications (Tylenol, Ibuprofen, etc.)
Prescription medications
Physical therapy
Chiropractic care
Injections
Massage
Other
Select all that apply.
Other reliever (please specify) - required; type N/A if not applicable
*
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