Joint/pain Evaluation Chart & Questionnaire Template


Joint/Pain Evaluation Chart & Questionnaire
Name: _______________________________________
Date: ________________
Primary Onset (check one)  Chronic issue,  Sports injury,  Car Accident,  Work Injury
Indicate the location of pain/discomfort above. Use the symbol that best describes the feelings:
XXX sharp/stabbing
PPP pins/needles
DDD dull/aching
NNN numbess
 Leg pain – numbness/tingling  Arm pain – numbness/tingling  Weakness – numbness/tingling
Daily Living Questionnaire
What type of work do you do? _______________________________________ Hours per day? ____________________
Hours per day prior to pain/discomfort? ________________________
How is your work affected? ___________________________________________________________________________
Home and Family list the activities affected by your exacerbation:
Sleep: How many hours of sleep per night do you sleep now? _______________ prior ______________
Do you feel your sleep is affected? If yes, explain briefly
Social/Recreational: Activities ________________________________________________________________________
How are your current activities affected? ________________________________________________________________


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