Patient Health History - Intake Form Page 2
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8Patient Name:
Date:
Please Draw the Location of Your Pain Using the Symbols Shown Below
Right
Left
Left
Right
D = Dull B = Burning N = Numb S = Stabbing T = Tingling C = Cramping
What is your Pain Right Now?
What is your pain level at its best?
No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst Possible
No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst Possible
What is your typical or Average Pain?
What is your pain at its worst?
No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst Possible
No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst Possible
Venous History
Please circle which symptoms you currently have or have had:
Tenderness
Ankle Swelling
Leg Cramps
Leg Pain
Open Sore/Ulcer
Red Warm Areas
Restless Legs
Heaviness
Injury / Pain Information
What caused your pain?: □ Work Related
□ Car Accident Date:
□ Other Describe:
When did your current episode begin?
How often does the pain occur? □ Continuously
□ Daily
□ Several Times a Week
What makes it worse? □ Sitting
□ Standing
□ Walking
□ Other:
What makes it better?
Where is your 1st problem?
Where is your 2nd problem?
Does the pain interrupt your sleep: □ Yes
□ No
Page 2
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Parent category: Medical