PATIENT INFORMATION
First Name
Last Name
Date of birth
What is your CURRENT level of pain? (Do not exaggerate, so we can best assess your pain)
1
2
3
4
5
6
7
8
9
10
What is your HIGHEST level of pain? (Do not exaggerate, so we can best assess your pain)
1
2
3
4
5
6
7
8
9
10
What does your pain FEEL like?
Stabbing
Burning
Shooting
Throbbing
Aching
Numb
Tingling
Other
How much of the day are you in pain?
Up to 25%
Up to 50%
Up to 75%
More Than 75%
How many total hours of sleep do you achieve?
How many times do you wake up because of your pain?
0 - 1 times
2 - 3 times
4 or more times
Are you WORKING?
Yes
No
How many hours a week are you working?
Less than 10 Hours
11 - 20 Hours
21 - 30 Hours
Full Time
How often do you currently SMOKE?
Never
Rarely
1 - 2 times a week
3 - 5 times a week
Everyday
Have you ever suffered from DRUG and/or ALCOHOL addiction or abuse?
Yes
No
What is your MARITAL STATUS?
Single
Married
Separated
Divorced
Widowed
Do you have any Family Members who suffer from severe DEPRESSION and/or ANXIETY disorder?
Yes
No
Do you have any Family Members who suffer from DRUG and/or ALCOHOL addiction?
Yes
No
Do you EXERCISE?
Yes
No
How many times do you exercise per WEEK?
1 - 2
3 - 4
5 - 6
7 or more
How long do you exercise per SESSION?
What exercises do you do?
Walking
Hiking
Stretching
Gym
Biking
Treadmill
Elliptical
Yoga
Swimming
Weights
Check the boxes if you experience ANY of the following:
Recent Weight Loss
Fever or Chills
Excessive Thirst
Frequent Nosebleeds
Hearing Loss
Chest Pain
Shortness of Breath
Heartburn
Bloody Stool
Weakness with Urination
Weakness with Bowel Movements
Take Blood Thinners
Red, Hot, or Swollen Joints
Frequent Anxiety
Depression
In the last 30 days, how much has your pain interfered with DAILY or GENERAL activities?
0
1
2
3
4
5
6
7
8
9
10
In the last 30 days, how much has your pain interfered with RECREATIONAL, SOCIAL, or FAMILY activities?
0
1
2
3
4
5
6
7
8
9
10
In the last 3 months, how many days have you been UNABLE to do housework or schoolwork?
0 - 3 Days
4 - 7 Days
8 - 14 Days
More than 14 Days
Submit Form