6. How Did Your Problem Begin?Please Explain
Auto Accident Work Related Accident Other Type Of Accident
Gradual Sudden No Specific Reason
7. What Makes Your Problem Better?
Nothing Walking Standing Sitting Moving Around/Exercise Lying Down Inactivity
8. What Makes Your Problem Worse?
Nothing Walking Standing Sitting Moving Around/Exercise Lying Down Inactivity
9. Are You Currently Taking Any Medication? Yes No
If Yes Please List
10. Were You Previously Treated For An Earlier Occurance Of The Same Condition? Yes No
If Yes, By Whom? MD Chiropractor Physical Therapist Other
What Were The Approximate Date, Type Of Treatment And Results?
11. What Is Your Physical Activity At Work?
Mostly Sitting Light Manual Labor Mostly Manual Labor Heavy Manual Labor
12. Do You Exercise?Patient Health Assessment
No Regular Exercise. 1-2 Times a week. 3-4 Times a week. 5-7 Times a week.
Cardiovascular. Streching. Weight Machine. Free Weights.
Sports
Type
 
13. What Is Your Stress Level?
 
No Stress. Minimal Stress. Moderate Stress. Greatly Stressed.
 
14. Is Your Problem Affecting Your Ability To Work Or Do Other Routine Daily Activities?
No Effect Have Some Limited Physical Restrictions, But Can Function
Need Some Assistance With Daily Activities Cannot Work
Cannot Function Without Assistance Totally Disabled