Body part being seen for:
Side of Body: Right Left Both
Date Symptoms Began:
Was there an injury? Yes No
Workers Comp? Yes No
Date of Injury:
If so, how did it happen?
If there is pain, where is it located?
Have you had any diagnostic imaging related to current injury/problem? Yes No
Possible pregnancy now? Yes No
Are your symptoms? Improving Worsening Stable
Are your symptoms? Mild Mild/Moderate Moderate Moderate/Severe Severe
What activities or body positions make your symptoms worse?
(ex. Walking, running, reaching overhead)
Have you had prior treatment?
(ex. Injections, surgery, physical therapy)