PATIENT MEDICAL QUESTIONNAIRE

Patient First Name

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Patient Last Name

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Date of Birth

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Primary reason for appointment(list single problem here)

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Where is your problem / pain is located?

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How long have you had the problem?

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Please rate your pain on scale from 0-10(0 being no pain-10 severe pain)?

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Describe pain in detail

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Numbness/Tingling

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Bowel/Bladder Function

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Unilateral Weakness

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Therapy trialed for 6 weeks or more.

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Exercise trialed for 6 weeks or more.

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Is there any exacerbating factors that bring on the pain?

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Is there anything that relieves the pain?

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Is there any additional information you would like to add?

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