Quickcharts Patient Case History Template Page 3
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3What is your SECOND complaint? _______________Date problem began?_______________
How did this problem begin (falling, lifting, etc.)?______________________________________________
How is your condition changing? □GETTING BETTER □GETTING WORSE □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)
□1 □2 □3 □4 □5 □6 □7 □8 □9 □10
How do your symptoms affect your ability to perform daily activities such as working or driving?
(0= no effect and 10= no possible activities) □1 □2 □3 □4 □5 □6 □7 □8 □9 □10
What activities aggravate your condition (working, exercise, etc)?_________________________________
What makes your pain better (ice, heat, massage, etc)? __________________________________________
What is your next complaint? ________________________Date problem began?_____________________
How did this problem begin (falling, lifting, etc.)? _____________________________________________
How is your condition changing? □GETTING BETTER □GETTING WORSE □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)
□1 □2 □3 □4 □5 □6 □7 □8 □9 □10
How do your symptoms affect your ability to perform daily activities such as working or driving?
(0= no effect and 10= no possible activities) □1 □2 □3 □4 □5 □6 □7 □8 □9 □10
What activities aggravate your condition (working, exercise, etc)? _________________________________
What makes your pain better (ice, heat, massage, etc)? _________________________________________
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