1) Please circle or describe on the diagram below where your current injury is. If you have more than one injury, please label them by priority as 1,2,3 etc. 2) Please describe the type of pain using one or two words (ie. Shooting, burning, aching, deep etc 3) Please provide the average severity of pain on a 0-10 scale (0 = no pain, 10 = worst pain ever)
History of Injury: Please provide the back story to your injuries Provide as much detail as possible (how it happened, long ago this began, treatments received, hospital visits for it, etc.):
Special Questions: Please select if any of the below are apply.
History of steroid use
Weight loss for unexplained reason
History of malignancy/cancer
History of tuberculosis
Significant night pain
Spinal Questions: Please select if you are experiencing any of the below.
Bladder or bowel incontinence
Numbness in sitting/saddle region
Sensation or motor deficit
CAD: Please select if you are experiencing any of the below.
Numbness of face or tongue
General Health Questions: Please select if you have been diagnosed/experience any of the below.
Cardiac conditions (ie. stroke, blood clot, heart attack)
Aggs: What makes the symptoms worse/irritates the injury?
Eases: What makes the symptoms better/relieves the injury?
24 Hour Pain/Symptom Pattern (please describe how your pain changes throughout the day. le. worse in morning VS. night):
Symptom Irritability (how easily is your pain/symptoms provoked & relieved):
Activities: What daily activities are you most limited in performig due to this injury?
Range of motion: What muscles and/or movements feel stiff or tight?
Strength: What muscles and/or movements do you feel weakness in?
Tenderness: What muscles/joints/tissue do you feel symptom provocation/pain upon touching?
Sensation: Do you have any loss of sensation/numbness/pins and needles anywhere? If so please describe where.
Balance/Falls: Do you have any balance concerns due to this injury? Have you had any falls due to this injury? If so please describe.
Others: Please described any other concerns related to your injury/condition (ie. co ordination, proprioception, vision, hearing, confusion, cognition, communication):
Past Medical History/Medical Conditions: Please list any other conditions you have or previously had:
Current Medications: Please list the names of any medications you are taking, what they are for, and if they have any side-effects that may affect your physical performance.
Goals: What are your rehab goals? (please be as specific as possible)
Should be Empty: