Name:

Date:

Phone:

Address

Date of Birth:

Email:

Insurance:

Occupation:

Referral from:

Primary MD:

Reason for Referral:

Date of onset:

List all activities that you cannot do because of your current problem: “current level of function”:

What activities make your problem worse?

What function(s) do you hope to change by coming to therapy? What are your Goals?

Pain Questionnaire

History of Onset

When did this current episode of pain begin?

Did the pain/problem begin:

gradually

suddenly

If your pain is due to an injury, briefly describe the events that led to the injury.

Have you had prior episodes of this pain/problem?

Yes

If yes, how many episodes have you had?

When did the first episode begin?

Is this episode worse than the previous episode?

Explain what caused the prior episodes:

Use the diagram and symbols to indicate where your pain is.

Ache: AAA
Burning: XXX
Numbness: OOO
Pins/Needles: …
Stabbing: ///

Please check the activities tht affect the pain/problem.

Coughing

Better

Worse

No Change

Sneezing

Better

Worse

No Change

Straining

Better

Worse

No Change

Standing

Better

Worse

No Change

Walking

Better

Worse

No Change

Sitting

Better

Worse

No Change

Lifting

Better

Worse

No Change

Pushing/Pulling

Better

Worse

No Change

Driving

Better

Worse

No Change

Bending Forward

Better

Worse

No Change

Lying on Stomach

Better

Worse

No Change

Overhead Reaching

Better

Worse

No Change

Squatting

Better

Worse

No Change

Kneeling

Better

Worse

No Change

Typing/Writing

Better

Worse

No Change

Intercourse

Better

Worse

No Change

Please select the number that best represents your level of pain.

Medical History

If you had surgery for this or a different problem, complete the following for each operation

Surgery Type

Date:

Effact:

Worse

Same

Better

Type of Improvement

Surgery Type

Date:

Effact:

Worse

Same

Better

Type of Improvement

During the past month have you often been bothered by feeling down, depressed, or hopeless?

Yes

During the past month, have you often been bothered by little interest or pleasure in doing things?

Yes

Is this something with which you would like help?

Yes

Yes, but not today

Allergies (please list)

Date

What Area of Body/Results

Other

Date

What Area of Body/Results

Medications:

Type

Dosage

How long have you been on it?

Medications:

Type

Dosage

How long have you been on it?

Medications:

Type

Dosage

How long have you been on it?

Medications:

Type

Dosage

How long have you been on it?

Developmental History:

Note any development delays or the need for corrective bracing as child/teenager.

Therapy History

If you have had therapy/chiro in the past, please indicate where, when, and how long you attended.

Place a check next to the type of treatment you received and how it affected your pain/problem.

Hot Packs/Ultrasound

Helped

No Effect

Made Worse

Ice/Cold Treatments

Helped

No Effect

Made Worse

Massage/Myofascial/Craniosacral

Helped

No Effect

Made Worse

Traction

Helped

No Effect

Made Worse

TENS

Helped

No Effect

Made Worse

Muscle Stimulator

Helped

No Effect

Made Worse

Chiropractic/Adjustments

Helped

No Effect

Made Worse

Acupuncture

Helped

No Effect

Made Worse

Bracing/Splinting

Helped

No Effect

Made Worse

Strengthening Exercises

Helped

No Effect

Made Worse

Flexibility Exercises/Yoga

Helped

No Effect

Made Worse

Are you currently receiving any of the aforementioned treatments now?

Yes

Personal History

Regular Exercise (what and how often)

Dietary Habits (caffeine, alcohol, citrus, nutrisweet, servings of fruits/vegetables, bread)

Fluid Intake/Day

Sleep Habits (trouble falling asleep, staying asleep, reason for awakening, resting in am?)

Gender Related History:

Please provide information on any of the following that apply to you

Female Gynecological History:

Have your menstrual periods stopped?

Yes

On hormone replacement therapy?

Yes

If yes, which one?

Date of last pelvic exam:

Do/Did you have pain with your menstrual periods?

Do/Did you have pain with intercourse?

Other GYN

Female Obstetrical History for each of your children:

Please provide as much information as possible

Birth Date

Weight

Vaginal/Cesarean

Prolonged Pushing?

Tearing/Forceps

Birth Date

Weight

Vaginal/Cesarean

Prolonged Pushing?

Tearing/Forceps

Birth Date

Weight

Vaginal/Cesarean

Prolonged Pushing?

Tearing/Forceps

Males: Prostate/Testicular Problems?

Please answer if Pelvic Floor Concerns

Answer any that apply to you; place additional comments in margins

How many accidents/day: Small (less than ½ cup)

BLADDER

BOWEL

How many accidents/day: Large (greater than ½ cup)

BLADDER

BOWEL

Do you wear protection? ( BLADDER )

Yes

If yes, what type?

Number of changes/day?

How often do you use the toilet during the day?

Do you wear protection? ( BOWEL )

Yes

How often do you use the toilet during the day?

If yes, what type?

Number of changes/day?

Do you experience strong urges to urinate or have a BM? ( BLADDER )

Yes

If yes, how much warning time to get to the toilet?

Do you experience strong urges to urinate or have a BM? ( BOWEL )

Yes

If yes, how much warning time to get to the toilet?

Do you ever leak when have a strong urge? ( BLADDER )

Yes

Do you ever leak when have a strong urge? ( BOWEL )

Yes

How many times do you get up to urinate at night?

Do you feel you are able to empty completely? ( BLADDER )

Yes

Do you have pain/burning with voiding? ( BLADDER )

Yes

Do you have any trouble starting your stream? ( BLADDER )

Yes

Do you dribble after urinating? ( BLADDER )

Yes

Do you feel you are able to empty completely? ( BOWEL )

Yes

Do you have pain/burning with voiding? ( BOWEL )

Yes

Do you have any trouble starting your stream? ( BOWEL )

Yes

Do you dribble after urinating? ( BOWEL )

Yes

Do you ever see blood in your urine or in your bowel movements?

Does your urine have a noticeable color or odor? Please explain

Do you experience abdominal bloating or tenderness?

Do you have constipation or diarrhea or both?

Any other comments or questions that have not been addressed above?