Medical History Intake Form Page 3
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8SYMPTOMATOLOGY (Pain Characteristics for Major Area of Complaint):
The pain started _____________________________________________________________________________________________
The pain is made better by ____________________________________________________________________________________
and worse by ________________________________________________________________________________________________
The pain has the following qualities: ____________________________________________________________________________
There is
There is not
radiation into
____________________________________________________________________
There is
There is not
referred pain into
_________________________________________________________________
There is
There is not
parasthesia (tingling/numbness) into:______________________________________________ _____
The pain is located ___________________________________________________________________________________________
The pain is (as far as timing is concerned: i.e. comes & goes, constant, etc.)______________________ ____________________ ___
DAILY ACTIVITIES
PAIN RATING
How many days out of an average week do you have pain? __________
On a scale of 1- 10, rate your pain
How much time out of an average day are you in pain? _____________
None
0 1 2 3 4 5 6 7 8 9 10
Severe
What are the worst times of day for the pain? _____________________
Describe the overall severity of the pain
Mild Nuisance
What are the best times of day for the pain? _______________________
Mild to moderate but can live with it
Moderate, having trouble coping with it
How do the following activities affect your pain?
Severe, it is ruining my quality of life
No Change
Relieves
Increased
Duration
Sitting
________
Progression
Walking
________
How is your pain compared to when it first
Standing
________
appeared?
Lying Down
________
Much improved
Looking up
________
Somewhat improved
Looking Down
________
No change
Lifting
________
Somewhat worse
Much worse
What do you do to relieve the pain? _____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What are some recreational activities that you participated in before this current problem and which ones cannot be
performed now to the same extent as before? _____________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List your hobbies and exercise activities: ________________________________________________________________________
____________________________________________________________________________________________________________
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
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