PATIENT INFORMATION

First Name

Last Name

Date of birth

Are you taking any medication for your pain? (ask our office if you are uncertain)

YES, I am taking pain medication

Are you taking Opioids?

YES, I am taking Opioids

Are you WORKING?

Yes

No

Do you EXERCISE?

Yes

No

How many times do you exercise per WEEK?

1 - 2

3 - 4

5 - 6

7 or more

Are you LIMITED from performing any activities?

Bathing / getting dressed

Light Housework

Climbing stairs

Walking

Enjoyment of life

Positive mood

With your CURRENT medications and treatments ...

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