Quickcharts Patient Case History Template - Short Form (Page 2 of 4) in pdf

Quickcharts Patient Case History Template - Short Form Page 2

Date of last physical examination: _________________ Do you smoke

- how many per day? _________________

Do you exercise

__________________________________________________

PLEASE MARK YOUR AREAS OF PAIN ON THE DIAGRAM BELOW

Main reason for consulting the office:

Become pain free

Explanation of my condition

Learn how to care for my condition

Reduce symptoms

Resume normal activity level

What is your major complaint? _________________________________Date problem began? _____________________

How did this problem begin (falling, lifting, etc.)? _________________________________________________________

How is your condition changing?

GETTING BETTER

GETTING

NOT CHANGING

Have you had this condition in the past? YES - NO

How often do you experience your symptoms?

Constantly (76-100% of the day

Frequently (51-75% of the day)

Occasionally (26-50% of the day

Intermittently (0-25% of the day)

Describe the nature of your symptoms:

Sharp

Dull

Numb

Burning

Shooting

Tingling

Radiating Pain

Tightness

Stabbing

Throbbing

Other: __________________________________________________________

Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain)

How do your symptoms affect your ability to perform daily activities such as working or driving?

(0= no effect and 10= no possible activities)

What activities aggravate your condition (working, exercise, etc)? _____________________________________________

What makes your pain better (ice, heat, massage, etc)? ______________________________________________________

Quickcharts Patient Case History Template - Short Form Page 2