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? ________________________________________________________________
__________________________________________________________________________________________________
________________________________________
_______________________________________
Signature
Date