COMPREHENSIVE QUESTIONNAIRE
Initial intake
Email address *
Today's date
MM
/
DD
/
YYYY
PATIENT NAME *
Your answer
Primary Complaint *
Your answer
How long have you had this problem? *
Your answer
Have you had this in the past? *
Your answer
How does this interfere with your daily activities? *
Your answer
What makes it better?
Your answer
What makes it worse?
Your answer
How do you feel today? *
Circle your pain level today
What is your worst pain last week? *
Circle your answer
How much does your pain interfere with your daily activities? *
Circle your answer
What types of treatment have been helpful for your condition?
Your answer
List any surgeries, hospitalizations, trauma, or accidents
Your answer
Do you have any pain in:
TCM Diagnostic questions, please check all that applies or has applied
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