Initial Medical Evaluation Form (Page 2 of 3) in pdf

Initial Medical Evaluation Form Page 2

Using the appropriate symbols, mark on the body diagram where you feel the following sensations:

Numbness

Pins and Needles

Burning

Stabbing

Aching

===

○○○

xxx

///

***

Does your pain radiate? Yes, where________________________________

Numbness, tingling, or weakness? Yes, where___________________________________

What makes your pain worse? _______________________________________________________________

_________________________________________________________________________________________

What makes your pain better?_______________________________________________________________

__________________________________________________________________________________________

What is your goal for your treatment?_________________________________________________________

What activity would you like to resume?_______________________________________________________

How long has it been since you have been able to perform this activity? _____________________________

When is your next Dr. appt.?_________________

Email (for receipt purposes only):____________________________________________

Patient Signature:___________________________

Date:______________________

FOR THERAPIST USE ONLY

COMMENTS:

Initial Evaluation:__________________________________________________________________________

__________________________________________________________________________________________

Therapist Signature________________________________________Date____________________

Initial Medical Evaluation Form Page 2