Pain Self Evaluation & Intake Form printable pdf download

Pain Self Evaluation & Intake Form

PAIN SELF EVALUATION & INTAKE FORM:

Name: ________________________________________________

Chief Complaint: Please describe the reason for your visit: _______________________________________________

_________________________________________________________________________________________________

Date of Injury or Onset of Pain _____/______/_____

Did it occur:

Gradually

Suddenly

Was it due to an injury, where did it occur?

Work

Home

Auto

Public

Other

Describe your pain including the location on your body where it hurts, does it go into your arms/legs

__________________________________________________________________________________________________

Please describe the location on your body where you have: Numbness: __________________________________

Tingling: __________________________

Weakness: _____________________________________________

Do you have good bowel and bladder control?

Yes

Do you have any of the following:

Balance problems

Difficulty with walking

weakness

Fevers

What word best describes the frequency of your pain:

constant

intermittent

waxing/waning

Is your pain worse in the

morning

afternoon evening

Since your pain has started, how has it changed:

Decreased

Increased

Unchanged

According to the above pain scale: What is your highest pain rating: _____ What is your lowest pain rating: ______

What is your daily average pain: __________

Pain Self Evaluation & Intake Form