Patient History
Please be as accurate as possible when answering the following questions. The more information we have, the better we can treat you. Our goal is always to help you to feel better as fast as possible.
What is bothering you today? *
Your answer
Rate the intensity of your pain *
Little to no pain
Extreme Pain
When did this problem begin? *
Your answer
Was there an incident that caused this issue? *
Your answer
Have you had this pain before? *
Your answer
What is the quality of the pain? (Check all that apply) *
Required
Do you have any numbness or tingling in your body? If so, where? *
Your answer
How frequently are you experiencing this issue, and how long does it last? *
Your answer
Is your complaint getting better, getting worse or has it remained unchanged since it began? *
Your answer
Is there any daily activity you have difficulty with or can no longer do? *
Your answer
Does that pain or discomfort interrupt your sleep? *
Required
Does anything aggravate the complaint (ie a position or activity)? *
Your answer
Does anything make the pain or discomfort better (ie stretching, icing, medication)? *
Your answer
Has this issue affected your daily life? (choose all that apply) *
Required
Have you noticed any significant changes in your current constitution? (choose all that apply) *
Required
List medications and reason for taking below: *
Your answer
List any surgeries that you have had: *
Your answer
What is your sleeping position? *
Your answer
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