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Patient Medical Form
First name
*
Last name
*
Current Symptoms
Headaches
Left
Right
Both
Front of Head
Top of Head
Back of Head
Jaw
Left
Right
Both
Eye
Left
Right
Both
Neck
Left
Right
Both
Upper Back
Left
Right
Both
Mid back
Left
Right
Both
Lower Back
Left
Right
Both
Chest
Left
Right
Both
Abdomen
Left
Right
Both
Ribs
Left
Right
Both
Buttocks
Left
Right
Both
Shoulder
Left
Right
Both
Upper Arm
Left
Right
Both
Forearm
Left
Right
Both
Hand
Left
Right
Both
Hip
Left
Right
Both
Leg
Left
Right
Both
Foot
Left
Right
Both
Types Of Pain
Check all that apply
Dull
Sharp
Aching
Cutting
Throbbing
Burning
Numbing
Tingling
Cramping
Spasm
Stinging
Shooting
Pounding
Constricting
Other (Explain here)
Pain Frequency
Check all that apply
Up to 1/4 of awake time
1/4 to 1/2 of the time
1/2 to 3/4 of awake time
Most of the time
Pain Intensity
(How it affects your Daily activities)
Check all that apply
Doesn't Affect
Somewhat Affects
Seriously Affects
Prevents Activities
Does The Pain Radiate Into Other Body Parts?
Head
Left
Right
Both
Neck
Left
Righ
Both
Shoulder
Left
Right
Both
Arm
Left
Right
Both
Hand
Left
Right
Both
Hip
Left
Right
Both
Leg
Left
Right
Both
Foot
Left
Right
Both
Other locations of radiation
Actions Affecting This Pain
In the A.M.
Brings On
Aggravates
Relieves
In the P.M.
Brings On
Aggravates
Relieves
Bending Forward
Brings On
Aggravates
Relieves
Bending Back
Brings On
Aggravates
Relieves
Bending Left
Brings On
Aggravates
Relieves
Bending Right
Brings On
Aggravates
Relieves
Twisting Left
Brings On
Aggravates
Relieves
Twisting Right
Brings On
Aggravates
Relieves
Coughing
Brings On
Aggravates
Relieves
Sneezing
Brings On
Aggravates
Relieves
Straining
Brings On
Aggravates
Relieves
Standing
Brings On
Aggravates
Relieves
Sitting
Brings On
Aggravates
Relieves
Lifting
Brings On
Aggravates
Relieves
Other Actions
Date
*
Month
Day
Year
Signature
*
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