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New Patient Inital Complaint Form
In order to gain a complete and accurate understanding of your current problem, we need you to answer a few questions. This information will help guide our assessments, establish medical necessity, and formulate an appropriate treatment plan. Please be thorough.
Complaint Description
Which of the following best describes your discomfort? Mark as many as apply.
How often do you experience the above discomfort?
Complaint Location
Please indicate where on your body this discomfort is felt.
Which side of your body is the discomfort felt?
If multiple areas of discomfort, which one is your primary concern?
Your answer
Complaint Rating
Current Discomfort Level
very mild
most severe possible
Complaint Rating
The worst your discomfort has been since it started...
very mild
most severe possible
Functional Difficulties
Due to your discomfort, which activities have been difficut for you?
Which of the following has your discomfort affected?
What do you believe to be the cause of this episode?
Your answer
Have you experienced any of the following in your past?
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