Today's Date How did you hear about us? Primary Dr. Family Friend Co-Worker Radio Internet Search/Close to home/work Yellow pages Drove by Hospital Insurance Plan Title Mr. Ms. Mrs. Dr. Rev. Miss Prof. Other Last Name * First Name * Middle Name * Birth Date * Sex * Male Female Social Security Number Address, City, State, Zip code * Primary Phone * Secondary Phone Work Phone Fax # Email Address Spouses Name Emergency Contact: First and Last Name Home Phone Cell Phone Email Address Name of Employer Address, City, State, Zip code Phone Number Fax # Current Medications and for what condition * Surgeries:
Surgeries continued
Continued
Continued
Chief Complaint * Is Your Chief Complaint in your: * Neck Low Back Mid Back Arms/Hands Legs/Feet Shoulders Hips What other complaints are you having? Is this condition *
Did this begin with: Auto:
Work Related:
Other Liability
No Injury Does it feel like *
Location *
Quality of Pain *
Level of Pain When Resting * Level of Pain Due to Symptoms (with Activity) * When did this begin? * Has this happened before? *
Yes
No
Is it worse in the *
Is it better with:
Worse With
Do you have *
Headaches: Location
Quality
Types Hat Band Cluster Migraine Tension Other (frequency/duration/time of day) Radiation: Left/Right Weakness: Left/Right Other Associated Signs and Symptoms:
Continued
Symptoms better with *
Continued
Condition's Effect of Job Performance
Daily Activities: Effects of Current Condition on Performance Bending *
Care - Infirm Family *
Carrying Groceries *
Change in Position - Sit to Stand *
Extended Computer Use *
Feeding *
Household Chores *
Kneeling *
Lift Children *
Lifting *
Pet Care *
Reading (Concentration) *
Self Care *
Self Care - Bathing *
Self Care - Dressing *
Self Care - Shaving *
Sexual Activities *
Sleep *
Static Sitting *
Static Standing *
Walking *
Yard Work *
List any recreational activities that your current condition has an effect on 
