Patient Medical Information

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Name:_________________ Date: _________
Patient Medical Information
Occupation ________________________________________
Leisure Activities ____________________________________
Use the scale below to answer the next 3 questions:
Your current level of pain while completing this survey __/10
The least your pain has been in the past 48 hours __/10
Please mark the location(s) on the diagram where you are
experiencing the problem(s) and describe the symptoms.
The worst your pain has been in the past 48 hours ___/10
X=sharp stabbing pain
///=Throbbing
History of Current Condition
O=Dull achy pain
--- = Burning
Give a brief description of the problem(s) for which you are seeking therapy:______________________________________________
++
____________________________________________________________________________________________________________
When did this problem begin?___________________________________________________________________________________
Treatment received so far for this problem (chiropractic, injections, etc.):________________________________________________
Have you ever had this problem before? Yes / No
If so, how was the problem treated?______________________________________________________________________________
How often do you wake at night due to your symptoms?______________________________________________________________
My symptoms are currently (circle one):
Getting Better
Getting Worse
The Same
Aggravating Factors: Identify up to 2 important positions and activities that make your symptoms worse:
1.__________________________________________________________________________________________________________
2.__________________________________________________________________________________________________________
Easing Factors: Identify up to 2 important positions or activities that make your symptoms better:
1. __________________________________________________________________________________________________________
2. __________________________________________________________________________________________________________
What are your goals for therapy?_________________________________________________________________________________
In the chart at the bottom please list three activities that you are having difficulty performing, or are unable to perform as a result of
your problem. Please rate the difficulty level based on a 0 – 10 scale. (10 is the most difficult)
Activity
Score 0-10
1.
2.
3.
Castle Medical Center Kailua, Hawaii
PATIENT ID
PATIENT INFORMATION
*364*
Pg 1 of 2
Rehab Evaluation and Assessment
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