Sciatica Physical Examination Form
Please complete this form for your sciatica physical assessment. All questions are relevant to your current symptoms and physical status.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How long have you been experiencing symptoms?
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Where do you feel the pain most?
*
Lower back
Buttock
Thigh
Calf
Foot
Other
How would you rate your pain today?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
What makes your pain worse?
Sitting
Standing
Walking
Bending
Lifting
Other
What helps to relieve your pain?
Rest
Heat/Ice
Medication
Stretching
Physical therapy
Other
Do you experience any of the following?
*
Numbness
Tingling
Weakness
Loss of bladder or bowel control
None of the above
What activities are limited by your symptoms?
Have you tried any treatments for your symptoms?
Medication
Physical therapy
Chiropractic care
Injections
Surgery
None
Other
Submit
Should be Empty: