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Name: _________________________________ DOB: _____/_____/______ Age: ______ Today’s Date: ____/_____/_____
Right □ Left □Ambidextrous
Height: ____Weight: ____ Hand dominance
Primary Care Provider: __________________Who referred you to the office:_________________________________________
Name of School:_________________________Coach’s name:____________________Sport:____________________________
Is this a work injury with a Workers Compensation Claim? □Yes □No Claim Number:________ Litigation pending? □Yes □No
Name of attorney (if applicable)____________________________Phone #___________________________________________
Work Status:
Currently Working:  Regular Duty
 Light Duty
 Not working due to this problem
Currently receiving or planning to receive disability? Yes
No
Current Job/Occupation: _______________________
8. How severe is your pain? (Rate on a scale from 0-10,
1. Body part we will be seeing you for (ex: left knee):
10 is worse)______________________________________
_____________
Right
Left ___________________
9. Does your pain keep you awake at night?
Yes
No
2. Date of injury or onset:__________________________
3. Describe where and how the problem occurred:
10. How often does the pain occur?
________________________________________________
Constant
Intermittent
Recurring
________________________________________________
11. How would you describe the pain?
Sharp
Dull
4. Have you ever injured this area before?
Yes
No
Stabbing
Throbbing
Aching
Burning
5. Have you been treated for this condition?
Yes
No
12. Do you have any of the following:
If yes, treating physician/ER: ________________________
Swelling
Bruising
Tingling
Weakness
Describe the treatment:_____________________________
Redness
Numbness
________________________________________________
13. What makes your symptoms worse?
6. Have you had any diagnostic studies
(Xrays, MRI, etc.)
Standing
Walking
Lifting
Bending
Exercise
done for this problem?
Yes
No
Twisting
Squatting
Kneeling
Stairs
Sitting
If yes, please list:
________________________________________________
Coughing/Sneezing
Other_______________________
Approx. Date:________________ Location performed:
14. What makes your symptoms better?
_______________________________________________
Rest
Ice
Heat
Other_______________________
7. What medications have you taken for this problem?
15. Since my problem started, it is now:
________________________________________________
Better
Worse
Unchanged
Any relief from those medications?
Yes
No
Partial
Temporary How long? __________________
NGPG 505001-03110 A (03/10/2016)

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