PAIN INDICATOR CHART
REFERRED BY DR. _________________________ DATE: ________________
PATIENT NAME LAST: _______________________ FIRST: _______________
In order to provide the best results, the doctor needs to know about your pain.
Check One: Auto accident_______ Work related injury _______Other ________
Date of accident or injury:____________
Briefly describe what happened:
List any previous surgeries with dates_____________________________________________
Please check if you are experiencing any of the following symptoms:
Headaches: Yes_____ No_____ Frequency___________ Severity___________
Radiculopathy: Yes_____ No____
(numbness/pain from shoulder-fingers or hips-feet
Indicate where your pain is located by marking area on diagram below. Mark area darker to
show more intense pain.
The technologist has explained the procedure(s) _______________________to me and I fully
understand and agree to the above stated test.
Page 2 of New Patient Packet
Corporate Office: 1931 W. Martin Luther King Jr. Blvd. • Suite F • Tampa, FL 33607 • Tel: (813) 514-2700 • Fax: (813) 849-6349
Scheduling Toll-Free: (888) ADG - 5575