Back and Spine CarePatient Health Questionnaire
Patient Name_______________________________________ Date______________________
Describe your symptoms____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
did your symptomsstart?____________________________________________________________________________ b.
did your symptomsbegin?____________________________________________________________________________
Indicate where you have pain or other symptoms2. How often do you experience your symptoms?
Constantly (76-100% of the day)Frequently (51-75% of the day)Occasionally (26-50% of the day)Intermittently (0-25% of the day)
3. What describes the nature of your symptoms?
Sharp Dull Numb ShootingBurning Tingling Sore Stabbing
4. How are your symptoms changing?
Getting Better Not Changing Getting Worse
5. How bad are your symptoms?
None UnbearableAt its WORST 0 1 2 3 4 5 6 7 8 9 10At its BEST0 1 2 3 4 5 6 7 8 9 10
6. How do your symptoms affect your ability to perform daily activities? (circle one)
Not at all A little bit Moderately Quite a bit Extremely Severe
7. What activity makes your symptoms worse?_____________________________________What activity makes your symptoms better?_____________________________________8. Who have you seen for your symptoms?
No One Chiropractor Medical Doctor Physical Therapist OtherWhat tests have you had for your symptoms and when were they performed?Circle all that apply X-rays CT Scan MRI Other
9. Have you had similar symptoms in the past?
Yes No If you have received treatment in the past for the same or similar symptoms, who did you see?Circle all that apply: This office Chiropractor Medical Doctor Physical Therapist Other
10. Are you currently seeing any health care providers for any other condition? Yes NoIf YES, please list provider(s) below:____________________________________________________________________________11. What do you hope to get form your visit/treatment (select all that apply)Reduced symptoms Resume/Increase activity Explanation of condition/treatmentLearn how to take care of this myself How to prevent this from occurring againOther____________________________Patient Signature_________________________________ Date________________________