Initial Pain Evaluation Form

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INITIAL PAIN EVALUATION FORM
Note: This is a confidential record and will be kept in your doctor’s office. Information contained here will not be releas ed to anyone without your
authorization to do so.
TODAY’S DATE
____/____/____
FAMILY DOCTOR
NAME_____________________________
DATE OF BIRTH ____ /____ /____
SOCIAL SECURITY #____________________
CHIEF COMPLAINT
What is the main reason for your visit today? (Describe your problem in detail)
-
Were you referred to us by another health care professional? (If yes please state name)_________________________
HPI:
Height: _______________
Weight: ______________
My current Problem is the result of a (check all that apply):
Car Accident
 Work Injury
 Legal Case
 Other _____________
When did the problem first start? ______________________________________________________
Date, if accident or work injury ________Has a workers’ compensation claim been filed?  Yes  No
Have you seen other physicians for this problem?
Yes
No
If so, who? __________________________
What treatments have you had for this problem?
Location of the problem:
(check all that apply)
 Physical Therapy
(check all that apply)
 Low Back
 Injections
 Buttock (Right Left Both)
 Chiropractic
 Leg (Right Left Both)
 Surgery
 Neck
 TENS
 Arm (Right Left Both)
Severity:
 Mild  Moderate  Severe
What activities make it better?
What activities make it worse?
 Rest
 Walking
 Stretching
 Sitting
 Ice
 Standing
 Heat
 Lying Down
 Riding / Driving
 Coughing / Sneezing
CSC INITIAL PAIN EVALUATION FORM 100510.doc
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