Q-1: What is the primary reason you are seeking treatment today?
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Q-2: Quality of pain (Select all that apply)
Burning
Dull
Sharp
Shooting
Aching
Throbbing
Pinching
Radiating
Q-3: Frequency of Pain
Occasionally (0 – 33% of the time)
Frequently (34 – 66% of the time)
Constantly (67 – 100% of the time)
Q-4: Current State of Pain
Improving
Worsening
Unchanging
Q-5: Location of Pain (Neck / Back)
Left Neck
Left Upper Back
Left Mid Back
Left Lower Back
Left Ribs
Right Neck
Right Upper Back
Right Mid Back
Right Lower Back
Right Ribs
Headache
Q-6: Location of Pain (Upper Extremities)
Left Shoulder
Left Arm
Left Elbow
Left Forearm
Left Wrist
Left Hand/Fingers
Right Shoulder
Right Arm
Right Elbow
Right Forearm
Right Wrist
Right Hand/Fingers
Q-7: Location of Pain (Lower Extremities)
Left Hip
Left Buttock
Left Thigh
Left Knee
Left Leg/Calf
Left Foot/Ankle
Right Hip
Right Buttock
Right Thigh
Right Knee
Right Leg/Calf
Right Foot/Ankle
Q-8: Pain Level (Please indicate on a 10-point scale how you rank the pain you’re experiencing)
0 (No pain)
1 (Minimal pain)
2
3
4
5 (Moderate pain)
6
7
8
9
10 (Worst possible pain)
Q-9: Activities of Daily Living. (How is pain affecting your daily routine? For example: washing, walking, driving, sleeping, care for children or pets?)
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