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Patient Health Assessment
General Information
Patient Name Date
Provider Name
Primary Care Physician
Sex M F Date Of Birth Marital Status S M W D Children Soc Sec
Patient Address City State Zip
Home Phone Work Phone
Patient Employer Patient Occupation
Subscriber Name Relation To Patient
Subscriber Employer Subscriber Soc Security #
Referred For Treatment By
Health Insurance Plan Group# Member#
Have You Ever Had Chiropractic Care? YesNo Where And When
Complaint History
1. Describe your current complaint and how the problem began.
How Long Have You Had This Condition?
2. How Would You Describe The Pain?
Sharp Soreness Throbbing Tingling Dull Stiffness
Spasm Burning Ache Weakness Numbness Shooting
3. How Would You Rate The Intensity Of Your Pain?
1 2 3 4 5 6 7 8 9 10   Pain level:
Click on a number to indicate your level of pain.
(No Pain) Moderate Pain Terrible/Unbearable Pain
4. How Often Is The Pain Present?
Constant (81-100%) Frequent (51-80%) Occational (26-50%) Intermitent (25% or less)
5. Since Your Problem Begain, Is The Pain?
Getting Worse Getting Better Staying The Same
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

 

SymptomPastPresent    SymptomPastPresent|
 |
Neck Pain      High Blood Pressure | Tobacco Use:
Shoulder Pain      Heart Condition | Past Present
Arm/elbow      Respiratory Condition | Occassional Moderate Heavy
Hand Pain      Digestive Problems |
Upper Back Pain      Kidney/Bladder Problems | Alcohol Use:
Lower Back Pain      Menstrual | Past Present
Pain In Right Leg Or Hip      Breast Soreness/lump | Occassional Moderate Heavy
Pain In Lower Leg Or Knee      Sinus Conditions |
Pain In Ankle Or Foot      Alergy/Asthma | Caffeine Use:
Jaw Pain      Cancer | Past Present
Swelling/Stiffness Of Joints      Sinus Conditions | Occassional Moderate Heavy
Headaches      Exessive Weight Loss/Gain |
Dizzyness      Skin Condition | Pregnancy: Past Present
Fainting Spells      Arthritis |
Convultions      Diabetes | Surgical Procedure: Past Present
General Perlogned Fatigue      Prostate Condition |
Condition Of Uterus/Overies Comments:
|Please List Surgical Procedures:
Use the pulldown menu to select the type pain and click a spot on the chart to indicate an area of pain.
Legend
Pain
Ache
Burning
Numbness
Pins & Needles
Stabbing

 
General Disability Index
      The rating scales below are designed to measure the degree to which several aspects of your life are disrupted by chronic pain.  In other words, we would like to know how much your pain is preventing you from doing what you would normally do, or from doing as well as you normally would.  Respond to each category by indicating the overall impact of pain in your life, not just when the pain is at its worst.
      For each of the six daily living categories listed PLEASE DRAG THE SLIDER TO THE NUMBER WHICH BEST DESCRIBES YOUR TIPICAL LEVEL OF ACTIVITIES.  A score of o means no disability at all, and each score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain.
1. Family/Home Responsibilities. This category refers to activities related to home or family.  It includes chores and duties performed around the house (e.g yard work) and errands or favors for other family members (e.g. driving the children to school).
Completely able to function
1 2 3 4 5 6 7 8 9 10   Pain level:
Click on a number to indicate your level of pain.
Totally unable
to function
 
2. Recreation. This category includes sports and other leasure time activities.
Completely able to function
1 2 3 4 5 6 7 8 9 10   Pain level:
Click on a number to indicate your level of pain.
Totally unable
to function
 
3. Social Activity. This category refers to activities which involve participation with friends and acquaintances other than family members.  It includes parties, theater, dinning out, and other social functions.
Completely able to function
1 2 3 4 5 6 7 8 9 10   Pain level:
Click on a number to indicate your level of pain.
Totally unable
to function
 
4. Occupation. This category refers to activities that are part of or or directly related to one's job.  This includes non paying jobs such as that of a homemaker or volunteer worker.
Completely able to function
1 2 3 4 5 6 7 8 9 10   Pain level:
Click on a number to indicate your level of pain.
Totally unable
to function
 
5. Self Care. This category includes activities which involve personal maintenance and independant daily living) eg. taking a shower, driving,getting dressed etc.
Completely able to function
1 2 3 4 5 6 7 8 9 10   Pain level:
Click on a number to indicate your level of pain.
Totally unable
to function
 
6. Life-Support Activity. This category refers to life-supporting activities such as eating, sleeping and breathing.
Completely able to function
1 2 3 4 5 6 7 8 9 10   Pain level:
Click on a number to indicate your level of pain.
Totally unable
to function
Total Score:
   

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