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Reason For Visit

When did your symptoms appear?

____________________________________

Is this condition getting progressively

worse? _______________________________

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Type of pain: ( Sharp ( Dull ( Throbbing ( Stiffness

( Numbness ( Aching ( Shooting ( Swelling

( Burning ( Tingling

( Cramps ( Other

Which word best describes the frequency of your symptoms? (select one)

( Constant (75%-to-100% of awake time) ( Frequent (51%-to-75% of awake time)

( Intermittent (26%-to-50% of awake time) ( Occasional (0%-to-25% of awake time)

Does it interfere with your: ( Work ( Sleep ( Daily Routine ( Recreation

Which phrase best describes changes in your symptoms throughout the day:

( Worse in the morning ( Worse in the afternoon ( Worse at night ( Changes with weather ( Does not change

Activities or movements that are painful to perform: ( Sitting ( Standing ( Walking ( Bending (Lying Down

Does anything help relieve your symptoms?

( Ice ( Heat ( Stretches ( Rest Medications _______________________________________ Other ______________________________

Check symptoms you have noticed:

( Headache ( Head Seems Too Heavy ( Pain Down Arms ( Fatigue

( Neck Pain ( Pins & Needles in Arms ( Pain Down Legs ( Loss of Memory

( Neck Stiffness ( Pins & Needles in Legs ( Ears Ring ( Tension

( Sleeping Problems ( Numbness in Fingers ( Hip Pain ( Irritability

( Back Pain ( Numbness in Toes ( Loss of Balance ( Depression

( Nervousness ( Weakness in Arms and Hands ( Fainting Spells ( Other_____________

( Buzzing in Ears ( Weakness in Legs and Feet ( Dizziness ( Other_____________

PAIN SCALE

Please list your areas of pain and circle the number that best describes it.

1) ___________________________________

0 1 2 3 4 5 6 7 8 9 10

NONE LITTLE MEDIUM SEVERE

2) ______________________________________________________

0 1 2 3 4 5 6 7 8 9 10

NONE LITTLE MEDIUM SEVERE

3) ______________________________________________________

0 1 2 3 4 5 6 7 8 9 10

NONE LITTLE MEDIUM SEVERE

4) ______________________________________________________

0 1 2 3 4 5 6 7 8 9 10

NONE LITTLE MEDIUM SEVERE

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• We invited you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.

• Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.

• I fully understand I am solely responsible for any balance not paid by my insurance company.

• I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices.

• I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

Signature _____________________________________________ Date _____________

(Adult Patient ( Parent or Guardian ( Spouse

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