• CONDITION QUESTIONNAIRE - UPDATE

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Region of Complaint / Reason For Visit

  • How would you describe your symptoms? (check all that apply)*
  • Does this radiate / travel (into arms, legs, etc)?*
  • Is this a result of:*
  • Change in condition*
  • Is there anything else the doctor should (or you would like the Dr) to know about this condition?*
  • Is there anything you are particularity concerned about regarding this condition?*
  • Have you had any change in your overall health status, new or worsening condition(s), injuries or surgeries since last treated at our office?*

  • 0-10 Severity scale

    - Mild pain / symptom range: 1-3

    - Moderate pain / symptom range: 4-6

    - Severe pain / symptom range: 7-10

    Symptom severity are rarely at a static level. Often times they will vary based on activity, time of day, position, etc. In order to better understand your symptoms, please rate how you feel now, how you feel on average (since the condition started), how you feel at its best and how you feel at its worst.

  • Pain / symptom level - RIGHT NOW:*
  • Pain / symptom level - TYPICAL or AVERAGE (since this problem started) not how you "typically" feel*
  • Pain / symptom level - AT ITS BEST*
  • Pain / symptom level - AT ITS WORST*

  • In order to properly assess your condition, we must understand how much your neck and/or back problems has affected your ability to manage everyday activities. For each item, please select the number which most closely describes your condition right now

  • 1. Pain Intensity*
  • 2. Sleeping*
  • 3. Personal Care (washing, dressing, etc.)*
  • 4. Travel (driving, etc)*
  • 5. Work (includes home related "work")*
  • 6. Recreation*
  • 7. Frequency of Pain*
  • 8. Lifting*
  • 9. Walking*
  • 10. Standing*
  • Should be Empty: