Patient Center

Primary Region of Complaint:

Which symptom are you most concerned about?
When did your symptom start (specific day/ date)?
OR has your symptom been going on for a long time?YesNo
What caused you to seek care or how did your symptoms begin?
What is the intensity of your primary symptom when it’s at its worst? (0 = No Pain and 10 = Worst Pain Possible)

How often do you experience your symptoms?
ConstantFrequentIntermittentOccasional

Is your pain worse when you get up in the morning or does it get worse throughout the day?
In the MorningThroughout the Day

Describe the nature of your primary symptom:
What aggravates your primary symptom?
SittingStandingWalkingBendingLiftingSleepingSneezingCoughingReachingTwistingLooking UpLooking DownGeneral MovementLying SupineDrivingTypingSitting at a computerHousehold ChoresExerciseStairs
Stepping does it radiate?
YesNo
If yes, to where? (Include a brief history, pain intensity and nature of the symptom)?
What diagnostic tests have already been performed (include time frame and specific area tested)?
What Doctors have you seen in the past and what types of professional treatments have you tried (include time from and if they helped)?
What types of self-treating is done at home to help relieve your pain?RestLying DownSittingStandingMovementApplying HeatApplying IceAnalgesic topical pain relief gelIbuprofen or other medicationStretchingExercise
How has your pain affected your life? Home life? Hobbies? Work?
What are some things you used to do before you had pain that you would like to do again if it was not a problem?

Can you remember a time, a specific time, before your pain started and affected you in the ways listed above?
YesNo
Tell me about it, what was it like, how did you feel, what did you do, etc.:
What happens if you do nothing?
If there were a way to fix this problem so you would not have to suffer with it any longer, would you want to?
YesNo
Trigger Points Finding: Secondary Region(s) of Complaint (include a brief history, pain intensity, nature of the symptom and prior treatments): Patient asked to bring a WRITTEN list of MEDICATIONS?
YesNo