Please Attach Medical Records As Appropriate. ______

 Please attach medical records as appropriate. ______

What are your goals for this visit? ______

______

______

What aspect of your pain, or which pain is the most bothersome to you?

______

Pain Intensity:

On a scale of 1-10 with “0” representing no pain, “1” representing a nuisance which would not interfere with daily activities while “10” would be the most severe pain imaginable, which number best describes your pain?

What is your worst pain?0 1 2 3 4 5 6 7 8 9 10

Overall average pain?Less pain0 1 2 3 4 5 6 7 8 9 10More pain

What is your pain like today?0 1 2 3 4 5 6 7 8 9 10

How many extremely bad days (horrible or excruciating pain) in a week do you experience?______

Check the box which best gives the intensity of your type of pain:

Mild Moderate SevereUnbearableLocation

1. Sharp    ______

2. Shooting    ______

3. Throbbing    ______

4. Cramping    ______

5. Stabbing    ______

6. Gnawing    ______

7. Hot Burning    ______

8. Aching    ______

9. Heavy    ______

10. Tender    ______

11. Splitting    ______

12. Tiring/Exhausting    ______

13. Sickening    ______

14. Fearful    ______

15. Punishing/Cruel    ______

How much time during an average day (24 hour period) are you in pain?

 Pain is not present daily Less than 1/3 of the time Almost 50% of the time

 Almost 2/3rds of the time Almost 24 hours Anytime that I am not laying down

Do any of the following make your pain change?

No Somewhat A Lot Somewhat Complete

ChangeWorseWorseBetterRelief

1. Sitting     

2. Standing     

3. Walking     

4. Bending forward     

5. Bending backward     

6. Bending to same side     

7. Bending to opposite side     

8. Lying Down/Resting     

9. Driving     

10. Lifting     

11. Coughing/Sneezing     

12. Cold weather     

13. Damp weather     

14. Sexual activity     

15. Overhead activity     

16. Other______

Are you able to perform any of the following without assistance?

1.Walk Yes  No4. Climb Stairs Yes  No

2.Sit Yes  No5. Dress Self Yes  No

3.Stand Yes  No6. Drive Car Yes  No

Please mark the box which best describes the changes in your desire to participate in the following activities since the onset of your pain?

No Decreased Decreased

IncreasedChangeSome Quite a Bit Disappeared

Personal Hygiene     

Household cleaning     

Family activities     

Recreation and hobbies     

Sexual relations     

Physical exercise     

Watching television     

How often do you have to stop your activities and sit down or lie down to control your pain?

 Rarely (not daily) Approximately once a day Several times a day

 I spend almost all day lying or sitting down to control my pain

Sleep Pattern

1. Has your sleep pattern changed due to pain?  Yes  No

2. Do you have trouble falling asleep? Yes  No

3. How many times do you wake up at night? ______How many nights a week? ______

4. How many hours do you actually sleep?______

5. How do you feel when you wake up in the morning? ______

6. Do you take sleep aids?  Yes  NoIf so, what?______

Previous treatments for this pain complaint and where:

 Chiropractor ______ Physical Therapy ______

 Psychotherapy ______ Epidurals ______

 Nerve Blocks ______ Cortisone Injections ______

 Oral Cortisone ______ Operations______

 Other ______

Previous Studies:

 X-Rays CT Scan MRI  Myelogram Bone Scan Nerve Conduction Study

 Other ______

Prior experiences you have had with alternative medicine? ______

______

Are you involved with any other therapies such as massage, acupuncture, chiropractic now? Previously?

______

What medications are you taking now? (Include prescription and over-the-counter drugs)

MedicationReasonWhen StartedDosage per DayCost

______

______

______

______

______

______

______

Medication Side Effects:ConstipationSwelling Sweating Sleepiness Other: ______

Allergic reactions to medications

MedicationReaction/Intolerances

______

______

______

Allergic reactions to chemicals/substances

Chemical/SubstanceReaction/Intolerances

______

______

______

What vitamins/mineral/supplements are you taking now?

Brand or Other NameReasonWhen StartedDosage per DayCost

(manufacturer)

______

______

______

______

______

______

______

What physical activity do you participate in? ______

______

What are the major stressors in your life? ______

______

What do you do to relax? ______

______

Past Operations

WhatWhenWhatWhen

______

______

______

______

Past Family Medical History

FatherMotherGrandparents SiblingsChildren

Heart Disease _____ _____ ___________ _____

Hypertension _____ _____ ___________ _____

Cancer _____ _____ ___________ _____

Diabetes _____ _____ ___________ _____

Lung Disease _____ _____ ___________ _____

Hepatitis _____ _____ ___________ _____

Digestive _____ _____ ___________ _____

Seizures _____ _____ ___________ _____

Thyroid Disease _____ _____ ___________ _____

Other ______ _____ _____ ___________ _____

Other ______ _____ _____ ___________ _____

Other ______ _____ _____ ___________ _____

Occupation

______

Are you presently working? Yes No 

What interests/hobbies do you have? ______

With whom do you live? (Include roommates, friends, partner, spouse, children, parents, relatives, pets)

NameAgeRelationshipNameAgeRelationship

______

______

______

______

Tobacco Never used Smoked from age _____ to ____. ____ packs per day.

Alcohol Never used Estimated drinks per day ____.

Other Drugs Never used Frequency ____.

What other things would you like us to know? ______

______

______

Who would you like us to send a consultation report to? ______

______

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