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2762252857501206500142240Bayview Medical Clinic00Bayview Medical Clinic1597025100330An Integrative Approach to Fibromyalgia Management00An Integrative Approach to Fibromyalgia Management-469900476885NEW PATIENT INTAKE FORM00NEW PATIENT INTAKE FORMINSTRUCTIONSBefore you begin, SAVE this form to your computer so you don’t lose your work. Remember to periodically save the form to avoid data loss, especially as you take breaks or leave your computer for extended periods,Instructions will be provided for each section. Please do not skip a section if the information is relevant to your health. Complete as accurately as possible. This is a comprehensive document and may take up to 90 minutes to complete. When you complete the form, open a new email and attach the form to the email address it to intake@. If you forget to return the form by the requested due date, your appointments will be cancelled.NOTE: This form has been redesigned from the original PDF format to allow for better compatibility with web browsers. It has been optimized to function in Microsoft Word. If you do not have Microsoft Word and would like the PDF version, please email the clinic at Intake@ and we will email it to you.While this has been tested on mobile devices, there are additional steps to take to download and save the form. If you are not very familiar with the mobile device and its nuances, it is recommended you use aPC or Mac to complete the form.901700137151Bayview Medical Clinic00Bayview Medical Clinic04000421206500178462An Integrative Approach to Fibromyalgia Management00An Integrative Approach to Fibromyalgia ManagementNew Patient Intake FormInstructions: This profile contains questions that will help us to better assess and treat your problem(s). Please read and answer each question carefully. This inventory is your account of your personal experience. Please complete it without assistance from anyone else and answer all questions as completely as possible.Name: FORMTEXT ?????Date of Birth FORMTEXT ?????Who is your primary care doctor? FORMTEXT ?????Who referred you to our clinic? FORMTEXT ?????DIAGNOSESCHRONIC DIAGNOSESCheck any chronic illness (greater than 3 months duration) for which you currently see a physician or take medications for on a regular basis: FORMCHECKBOX Alcoholism FORMCHECKBOX Anemia anxiety FORMCHECKBOX AIDS FORMCHECKBOX Arthritis asthma FORMCHECKBOX Back strain FORMCHECKBOX Bladder infection FORMCHECKBOX Recurrent bleeding problem FORMCHECKBOX Cancer FORMCHECKBOX Cirrhosis of the liver FORMCHECKBOX Colitis/ileitis FORMCHECKBOX Congenital defect FORMCHECKBOX Depression FORMCHECKBOX Dermatitis FORMCHECKBOX Diabetes (sugar) FORMCHECKBOX Eczema FORMCHECKBOX Emphysema FORMCHECKBOX Epileptic seizures FORMCHECKBOX Kidney stone FORMCHECKBOX Mental illness FORMCHECKBOX Migraine headaches FORMCHECKBOX Mononucleosis FORMCHECKBOX Neck strain FORMCHECKBOX Nervous stomach FORMCHECKBOX Obesity FORMCHECKBOX Pelvic infection FORMCHECKBOX Rheumatic fever FORMCHECKBOX Sinus trouble – chronic FORMCHECKBOX Eye/vision problems FORMCHECKBOX Fibrocystic breasts FORMCHECKBOX Gallbladder problem FORMCHECKBOX Gonorrhea FORMCHECKBOX Gout FORMCHECKBOX Hay fever FORMCHECKBOX Hearing loss FORMCHECKBOX Heart problem FORMCHECKBOX Hepatitis FORMCHECKBOX Peptic ulcer FORMCHECKBOX Phlebitis FORMCHECKBOX Pneumonia FORMCHECKBOX Prostatitis FORMCHECKBOX Herpes- genital FORMCHECKBOX High blood fats (cholesterol,triglycerides) FORMCHECKBOX Hypoglycemia FORMCHECKBOX Hives FORMCHECKBOX Jaundice FORMCHECKBOX Kidney disease FORMCHECKBOX Stroke FORMCHECKBOX Suicide attempt FORMCHECKBOX Syphilis FORMCHECKBOX Tension headaches FORMCHECKBOX Temperomandibular joint (TMJ) FORMCHECKBOX Myofascial pain dysfunction (MPD) FORMCHECKBOX Thyroid disease FORMCHECKBOX Tuberculosis FORMCHECKBOX Vaginitis - chronic FORMCHECKBOX Other FORMTEXT ?????List any chronic illness (greater than 3 months duration) for which you see a physician or take medications on a regular basis, which is not mentioned above: Illness Date of Diagnosisa. FORMTEXT ????? FORMTEXT ?????b FORMTEXT ????? FORMTEXT ?????c. FORMTEXT ????? FORMTEXT ?????d. FORMTEXT ????? FORMTEXT ?????e. FORMTEXT ????? FORMTEXT ?????f. FORMTEXT ????? FORMTEXT ?????g. FORMTEXT ????? FORMTEXT ?????Have you ever seen a psychiatrist, psychologist, or counselor? FORMCHECKBOX Yes FORMCHECKBOX No If "yes" briefly state who, why and when: FORMTEXT ?????Have you ever been sexually or physically assaulted? FORMCHECKBOX Yes FORMCHECKBOX NoIf "yes" briefly state who and when FORMTEXT ?????Have you ever been diagnosed with a mental health illness? FORMCHECKBOX Bipolar Disorder FORMCHECKBOX PTSD FORMCHECKBOX Depression FORMCHECKBOX Panic Disorder FORMCHECKBOX Generalized Anxiety DisorderOther: FORMTEXT ?????PAST MEDICAL HISTORYMAJOR EVENTSList all surgeries in the order in which you had them:DateType of OperationHospital/CityReason for Surgerya. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????b. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????c. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? d. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????e. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????f. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????g. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????List all serious injuries in the order in which you had them:DateType of injuryTreatmentAny Disability?a. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????b. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????c. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????d. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????e. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????f. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????g. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ALLERGIESList all Drug Allergies in the order in which you had them: Allergy OnsetType of reactionSeveritya. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN b. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN c. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN d. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN e. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN f. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN g. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN List all Food Allergies in the order in which you had them: Allergy OnsetType of reactionSeveritya. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN b. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN c. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN d. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN e. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN f. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN g. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN List all Environmental Allergies in the order in which you had them: Allergy OnsetType of reactionSeveritya. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN b. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN c. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN d. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN e. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN f. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN g. FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FAMILY HISTORYList all significant medical diagnoses of family members.Father FORMTEXT ?????Mother FORMTEXT ?????Brother FORMTEXT ?????Brother FORMTEXT ?????Sister FORMTEXT ?????Sister FORMTEXT ?????Grandmother FORMTEXT ?????Grandfather FORMTEXT ?????Grandmother FORMTEXT ?????Grandfather FORMTEXT ?????Other FORMTEXT ?????Other FORMTEXT ?????PREVENTIVE CAREList the date of all your last preventive care servicesPhysical FORMTEXT ?????Mammogram FORMTEXT ?????Pap Smear FORMTEXT ?????Tetanus Shot FORMTEXT ?????Flu Shot FORMTEXT ?????Cholesterol FORMTEXT ?????Diabetic Screening FORMTEXT ?????Colon Cancer Screening FORMTEXT ?????Osteoporosis Screening FORMTEXT ?????Dental Exam FORMTEXT ?????SOCIAL HISTORYDo you smoke? If you answer “no”, skip to question 17. FORMCHECKBOX Never FORMCHECKBOX Former Smoker FORMCHECKBOX Current every day smoker FORMCHECKBOX Heavy tobacco smoker FORMCHECKBOX Current some day smoker FORMCHECKBOX Light tobacco smokerWhat do you smoke?Cigarettes FORMTEXT ????? packs/day, FORMTEXT ????? years Pipe FORMTEXT ????? amount/day FORMTEXT ?????years, contents of your pipe? FORMTEXT ????? Cigars FORMTEXT ????? day FORMTEXT ????? yearsHave you smoked in the past and quit? FORMCHECKBOX Yes FORMCHECKBOX NoIf "yes" what year did you quit? FORMTEXT ????How many total years did you smoke? FORMTEXT ?????How much were you smoking when you quit? FORMTEXT ?????DailyDo you use smokeless tobacco products? FORMCHECKBOX Yes FORMCHECKBOX No If "yes" what? FORMTEXT ????? Amount per day FORMTEXT ?????For how long FORMTEXT ?????Do you drink alcohol? FORMCHECKBOX Yes FORMCHECKBOX NoDid you formerly drink alcohol but stop? FORMCHECKBOX Yes FORMCHECKBOX No If "yes" what year did you stop? FORMTEXT ????How many total years had you been drinking? FORMTEXT ?????How much do /did you drink? FORMTEXT ???? Wine FORMTEXT ?????Glasses/week over FORMTEXT ?????yearsBeer FORMTEXT ?????Bottles or cans/week over FORMTEXT ?????years Liquor FORMTEXT ?????Drinks/week over FORMTEXT ?????yearsDo you exercise regularly? FORMCHECKBOX Yes FORMCHECKBOX NoIf "yes" what do you do? FORMTEXT ?????How many times/week? FORMTEXT ?????How many minutes/session? FORMTEXT ?????How vigorously? FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX StrenuousHow long have you been doing this FORMTEXT ?????What do you do for fun? How do you relax? FORMTEXT ?????Are you on disability? FORMCHECKBOX Yes FORMCHECKBOX NoAre you working? FORMCHECKBOX Yes FORMCHECKBOX NoEmployer FORMTEXT ?????Occupation Address: FORMTEXT ?????Work Phone: FORMTEXT ?????Please describe the kind of work you do, or what you did most recently (e.g. registered nurse, personnel manager, supervisor of order department, assembly line worker, store clerk) FORMTEXT ?????What are/were your most important activities/duties at work? (e.g. patient care, directing hiring policies, supervising order clerks, assembling engines, sales) FORMTEXT ?????What was the highest grade you completed in school? FORMCHECKBOX Ninth grade or less FORMCHECKBOX High School (but did not finish) FORMCHECKBOX High School graduate or equivalent (e.g. GED) FORMCHECKBOX Certificate of Professional School FORMCHECKBOX Vocational, Technical, or Business school FORMCHECKBOX Some College FORMTEXT ?????Year (s) completed FORMCHECKBOX College Graduate What is your present marital status? FORMCHECKBOX Married FORMCHECKBOX Single FORMCHECKBOX Separated FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMCHECKBOX Living with PartnerSpouse’s/Partner Name: FORMTEXT ?????What was your marital status when your pain problem began? FORMCHECKBOX Married FORMCHECKBOX Single FORMCHECKBOX Separated FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMCHECKBOX Living with PartnerIf you are in a relationship, is your spouse/partner employed? FORMCHECKBOX Yes FORMCHECKBOX NoWith whom do you live? (Please check all that apply.) FORMCHECKBOX No one FORMCHECKBOX Spouse/Significant FORMCHECKBOX Children FORMCHECKBOX Other (e.g.parents/relative) FORMTEXT ?????Do you have children? FORMCHECKBOX Yes Ages FORMTEXT ????? FORMCHECKBOX No 34 How would you rate your social support: FORMCHECKBOX Strong FORMCHECKBOX Fair FORMCHECKBOX WeakNUTRITIONAL HISTORYHave you ever tried an elimination diet? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what foods have you identified cause issues for you?FoodSymptoms it causes FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ADVANCED DIRECTIVEDo you have an Advanced Directive, Living Will or Healthcare Durable Power of Attorney? FORMCHECKBOX Y FORMCHECKBOX N If yes, we would be happy to keep a copy on file. Please bring one to the office.MEDICATIONS AND SUPPLEMENTSList all medications you are currently taking, including nonprescription (e.g. aspirin, antacids, etc.) and vitamin supplements:Name of medicine or vitaminDosage/Times a dayHow long have you taken it? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????REVIEW OF SYSTEMSIn the past year, have you had any of the following:Head/Neurologic FORMCHECKBOX balancing problems FORMCHECKBOX spinning sensation FORMCHECKBOX fainting spells FORMCHECKBOX convulsions/seizures FORMCHECKBOX muscle twitching FORMCHECKBOX memory problems FORMCHECKBOX frequent or severe headaches FORMCHECKBOX weakness in arms or legs FORMCHECKBOX numbness or tingling in arms or legsEyes FORMCHECKBOX persistent eye pain FORMCHECKBOX persistent watering or FORMCHECKBOX itching FORMCHECKBOX double vision FORMCHECKBOX unexpected decrease of vision in one eyeEars, Nose, Throat FORMCHECKBOX frequent earaches FORMCHECKBOX sore or itchy ear FORMCHECKBOX canals FORMCHECKBOX difficulty hearing FORMCHECKBOX frequent stuffy or runny nose FORMCHECKBOX frequent post-nasal drip FORMCHECKBOX frequent nose bleeds FORMCHECKBOX swelling in neck FORMCHECKBOX tooth abscess FORMCHECKBOX frequent toothaches or dental problems FORMCHECKBOX chronic sore on tongue or inside mouth FORMCHECKBOX bleeding or sore gums FORMCHECKBOX persistent hoarseness FORMCHECKBOX persistent sore tongueRespiratory FORMCHECKBOX frequent or persistent wheezing FORMCHECKBOX frequent or persistent cough FORMCHECKBOX frequent sputum production FORMCHECKBOX coughing up blood FORMCHECKBOX frequent or severe shortness of breath FORMCHECKBOX shortness of breath that interferes with daily activitiesCardiovascular FORMCHECKBOX heart murmur FORMCHECKBOX Irregular heart beat FORMCHECKBOX very rapid heart beat/palpitations at rest FORMCHECKBOX pressure in the chest FORMCHECKBOX frequent or severe chest pain FORMCHECKBOX with exertion FORMCHECKBOX at rest FORMCHECKBOX shortness of breath lying down – relieved by sitting up FORMCHECKBOX abnormal EKG FORMCHECKBOX ankle swelling FORMCHECKBOX calf pain when walking – relieved by restDigestive FORMCHECKBOX frequent nausea or vomiting FORMCHECKBOX vomiting of blood FORMCHECKBOX severe heartburn FORMCHECKBOX trouble swallowing FORMCHECKBOX black tarry stool FORMCHECKBOX frequent diarrhea or watery stool FORMCHECKBOX frequent constipation FORMCHECKBOX unexplained rectal bleeding FORMCHECKBOX frequent or severe abdominal pain FORMCHECKBOX poor appetiteGenitourinary/Sexual FORMCHECKBOX loss of urine control FORMCHECKBOX awaken at night to urinate FORMCHECKBOX frequently urinate more than 10 times a day FORMCHECKBOX frequent burning sensation upon urination FORMCHECKBOX trouble getting flow started FORMCHECKBOX blood in urine FORMCHECKBOX pain in flank accompanied by feverMen FORMCHECKBOX pus or drainage from penis FORMCHECKBOX rupture or swelling in groin FORMCHECKBOX nodule or swelling in testicle FORMCHECKBOX tender testicle FORMCHECKBOX difficulty achieving or maintaining an erection FORMCHECKBOX lack of interest in sexWomen FORMCHECKBOX irregular periods FORMCHECKBOX excessive bleeding within periods FORMCHECKBOX bleeding or spotting between periods FORMCHECKBOX vaginal bleeding after menopause FORMCHECKBOX menstrual cramps FORMCHECKBOX headaches FORMCHECKBOX bloating FORMCHECKBOX mood changes before your period FORMCHECKBOX vaginal itching or discharge FORMCHECKBOX lump in breast FORMCHECKBOX difficulty achieving orgasm FORMCHECKBOX lack of interest in sexMusculoskeletal FORMCHECKBOX frequent or severe back pain FORMCHECKBOX pain or stiffness in a jointIs it due to an injury? FORMCHECKBOX Yes FORMCHECKBOX NoSkin FORMCHECKBOX skin lesion FORMCHECKBOX sore that won't heal FORMCHECKBOX persistent rash FORMCHECKBOX persistent itching acneEmotional FORMCHECKBOX frequent periods of anxiety FORMCHECKBOX frequent or prolonged periods of sadness or depression FORMCHECKBOX desire to end it all FORMCHECKBOX feelings of inadequacy FORMCHECKBOX fatigue after a night’s sleep FORMCHECKBOX difficulty falling asleep FORMCHECKBOX awakening early in the morning FORMCHECKBOX pessimism about the future FORMCHECKBOX marital or family problemsSpiritual FORMCHECKBOX lack of meaning or direction in your life FORMCHECKBOX lack of spiritual guidance FORMCHECKBOX absence of a spiritual community FORMCHECKBOX confusion about the concept of God and the meaning of God in your lifeOther FORMCHECKBOX constant fatigue FORMCHECKBOX frequent or constant thirst FORMCHECKBOX unexplained swollen glands FORMCHECKBOX frequent hot flashes FORMCHECKBOX unexplained fever or chills FORMCHECKBOX a loss or gain of more than 5 pounds in the last yearFOCUSED HISTORYPersonal HabitsHave you ever felt that you ought to cut down on your drinking or drug use? FORMCHECKBOX Y FORMCHECKBOX NHave people annoyed you by criticizing your drinking or drug use? FORMCHECKBOX Y FORMCHECKBOX NHave you ever felt bad or guilty about your drinking or drug use? FORMCHECKBOX Y FORMCHECKBOX NHave you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? FORMCHECKBOX Y FORMCHECKBOX N56 Are there times when you drink very heavily for one or more days in a row? FORMCHECKBOX Y FORMCHECKBOX NIf "yes" how often? FORMTEXT ?????Do you use drugs or medication that affect your mood or help you to relax? FORMCHECKBOX Y FORMCHECKBOX NIf "yes" how often? FORMTEXT ?????Occupational HistoryPlease provide a list of your all jobs performed in the last five years:DatesEmployerPositionHazardous Exposure? 1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? 2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you have any symptoms or illness you attribute to your job? FORMCHECKBOX Yes FORMCHECKBOX No If “yes”, please describe FORMTEXT ?????Have you ever received worker's compensation? FORMCHECKBOX Yes FORMCHECKBOX NNUTRITIONAL HISTORYFatsSelect the number of times per week you eat meals or snacks at fast food establishments or restaurants, etc.? FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreSelect the number of chicken meals eaten per week? FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreSelect the number of servings of shellfish per week? 4-7 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreSelect the number of fish servings eaten per week? FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreHow many eggs do you eat per week? FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreWhat kind of milk do you drink? FORMCHECKBOX Skim FORMCHECKBOX 1% FORMCHECKBOX 2% FORMCHECKBOX Whole FORMCHECKBOX Coconut FORMCHECKBOX AlmondOther FORMTEXT ?????How many glasses per week do you drink? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreHow many servings (2oz. per serving) of cheese do you eat per week? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreHow many meals per week contain foods that are fried (i.e. fried eggs, french-fried potatoes, fried fish, potato chips, fried chicken)? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreFiberSelect the number of slices of whole grain bread you eat per week, (not white bread) FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreSelect the number of salads you eat per week FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreDo you add fiber to food or drinks? FORMCHECKBOX Yes FORMCHECKBOX NoIf "yes" how many tablespoons per/week? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreSelect the number of servings of fruit you eat per week? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreSelect the number of servings of cooked vegetables per week (include baked potatoes)? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreSelect the number of servings of beans per week? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreRefined CarbohydratesSelect the number of teaspoons of sugar added to coffee, tea, ice tea, etc. per day? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreSelect the number of soft drinks consumed per week? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreSelect the number of sweet desserts or snacks per week (cake, pies, ice cream, candy, etc.)? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or moreSaltDo you salt your food? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Light FORMCHECKBOX Medium FORMCHECKBOX HeavyNumber of times per day you eat foods high in salt such as popcorn, nuts, pretzels, potato chips,pickles, etc.? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 or morePlease indicate which of the following you eat or drink; Coffee FORMTEXT ?????cups/day or FORMTEXT ?????cups/weekTea FORMTEXT ?????cups/day or FORMTEXT ?????cups/weekSoft drinks FORMTEXT ?????bottles or cans/day FORMTEXT ?????week Chocolate FORMTEXT ?????dayPain ExperienceEach of the following questions is about your experiences or pain. Please answer questions as accurately as possible.When did the pain problem begin? FORMTEXT ?????(MM/DD/YY)83. Where is your pain? FORMTEXT ?????Check the words that describe your pain. FORMCHECKBOX aching FORMCHECKBOX throbbing FORMCHECKBOX shooting FORMCHECKBOX stabbing FORMCHECKBOX gnawing FORMCHECKBOX sharp FORMCHECKBOX tender FORMCHECKBOX burning FORMCHECKBOX exhausting FORMCHECKBOX tiring FORMCHECKBOX penetrating FORMCHECKBOX nagging FORMCHECKBOX numb FORMCHECKBOX miserable FORMCHECKBOX unbearableChoose one: FORMCHECKBOX occasional FORMCHECKBOX continuousWhat time of day is your pain the worse? FORMCHECKBOX morning FORMCHECKBOX afternoon FORMCHECKBOX evening FORMCHECKBOX nighttimeRate your pain by checking the number that best describes your pain at its worst in the last month. No PainExcruciating Pain FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Rate your pain by checking the number that best describes your pain at its least in the last month. No PainExcruciating Pain FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Rate your pain by checking the number that best describes your pain on average in the last month. No PainExcruciating Pain FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Rate your pain by checking the number that best describes your pain right now.No PainExcruciating Pain FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 1089. What makes your pain better? FORMTEXT ?????90. What makes your pain worse? FORMTEXT ?????What side effects or symptoms of the treatment/medicine are you having? Circle the number that best describes your experience during the past week.SymptomBarely NoticeableSevere enough to stopNauseaVomiting FORMCHECKBOX 1 FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 9 FORMCHECKBOX 10 FORMCHECKBOX 10Constipation FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Lack of Appetite FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Tired FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Itching FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Nightmares FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Sweating FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Difficulty Thinking FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Insomnia FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Check the number that describes how during the past week pain has interfered with your: SymptomDoes NotCompletelyGeneral ActivityMood FORMCHECKBOX 1 FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 9 FORMCHECKBOX 10 FORMCHECKBOX 10Normal Work FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Sleep FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Enjoyment of Life FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Ability to Concentrate FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Relations with Others FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Do you think that your pain problem is due to something more serious than, or different from, what the doctors have told you? FORMCHECKBOX Yes FORMCHECKBOX NoWhy do you think you have pain? What do you think is wrong? FORMTEXT ?????Which of these bests describes the circumstances related to the onset of the problem? FORMCHECKBOX Accident at work FORMCHECKBOX Accident (other than work) FORMCHECKBOX Pain ‘just began” FORMCHECKBOX Following illness FORMCHECKBOX Following surgery FORMCHECKBOX Following InjuryOther (please describe) FORMTEXT ?????Answer questions 96-103 only if you have experienced back/neck pain caused by an injury. (If there is no specific injury, skip to question 104.) These questions refer to your injury; answer them in terms of when you started to have problems with your back/neck.How many times have you seriously injured your back/neck? FORMCHECKBOX Once FORMCHECKBOX 2-3 FORMCHECKBOX 4-6 FORMCHECKBOX More than 6Please write the date of the injury which is most responsible for your present back/neck problem FORMTEXT ?????(MM/DD/YY)Please answer the remaining questionnaire referring to this injury.Where did your accident occur? FORMCHECKBOX Home FORMCHECKBOX Work FORMCHECKBOX Auto Accident FORMCHECKBOX Sports Accident Other FORMTEXT ?????Please describe briefly your accident/injury FORMTEXT ?????Did your symptoms begin immediately after your injury? FORMCHECKBOX Yes FORMCHECKBOX NoDid you have neck/back or extremity pain or problems before yourinjury? FORMCHECKBOX Yes FORMCHECKBOX NoIf you did have pre-existing problems, how much worse have you been since the accident? FORMCHECKBOX Definitely a lot worse FORMCHECKBOX Definitely some worse FORMCHECKBOX A little bit worse FORMCHECKBOX Unchanged FORMCHECKBOX Don’t knowIn general, has the intensity of the pain changed throughout the time you have had it? FORMCHECKBOX Yes FORMCHECKBOX NoIf "yes" has it: FORMCHECKBOX increasedClick the number on the scale that expresses the amount your pain of interference pain has on your normal/customary activities of living.No interferenceTotal interference FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Click the number on the scale that corresponds to the average daily intensity of your pain. No interferenceTotal interference FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10If it is not possible to completely relieve your pain, what level of pain would be acceptable for you to live with?No interferenceTotal interference FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10About how many times in the past year have you been to an emergency room because of a pain problem? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 +How many times have you been admitted to a hospital in the past year for any problems associated with pain? FORMCHECKBOX 0 FORMCHECKBOX 1-3 FORMCHECKBOX 4-7 FORMCHECKBOX 8-10 FORMCHECKBOX 11-13 FORMCHECKBOX 14 +Which types of the following diagnostic tests have been done?Type DateResultsRegular spine x-rays FORMTEXT ????? FORMTEXT ?????CT Scan FORMTEXT ????? FORMTEXT ?????Myelogram FORMTEXT ????? FORMTEXT ?????MRI Scan FORMTEXT ????? FORMTEXT ?????Discogram FORMTEXT ????? FORMTEXT ?????Bone Scan FORMTEXT ????? FORMTEXT ?????EMG FORMTEXT ????? FORMTEXT ?????Please list the physicians and chiropractors you have seen since your injury/or pain started. Indicate whether your pain got better or worse from the treatment you receivedDateChiropractor/PhysicianTest or TreatmentPain Better Worse FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Check any treatments that you have received and the corresponding response to that treatment Treatment HelpedMade DifferenceNo DifferenceHot Packs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ultrasound FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ice FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Massage FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Electrical stimulation during PT FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX TENS Unit for home use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Body mechanics training FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Strengthening exercise FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Aerobics (e.g. exercise bike) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Gravity inversion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Traction FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Bed rest FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Chiropractor treatment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Biofeedback FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Local (trigger point) injections FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Epidural injections FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Facet joint injections FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Back brace FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Acupuncture FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anti-inflammatory medication FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Narcotic pain medication FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Muscle relaxant medication FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anti-depressant medication FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Are you currently receiving any treatment listed above? If so, when was the last treatment? FORMTEXT ?????How does the following affect your pain?WorseBetterSameCough/sneeze FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sitting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Standing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Walking FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Bending forward FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Exercise FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Riding in a car FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lying on back FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lying on stomach FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX On side w/knees bench FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Feeling tense FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Have you had trouble with bladder or bowel control? FORMCHECKBOX Yes FORMCHECKBOX NoCheck the most appropriate item:I get weakness in certain parts of my leg. When this occurs the other muscles in my leg: FORMCHECKBOX usually continues to work okay FORMCHECKBOX get weakness that usually affects all of my leg FORMCHECKBOX I hardly ever get weakness in my leg.Do you ever get pain at the tip of your tailbone? FORMCHECKBOX Yes FORMCHECKBOX NoIn the past year have you had any time periods with very little pain? FORMCHECKBOX Y FORMCHECKBOX N List some of your hobbies or recreational activities you enjoy prior to your pain beginning. Place an "X" by those activities you can no longer do because of your pain. FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Check a number to indicate how much of a problem you have with each of the following:No interferenceTotal interferenceAnxiety FORMCHECKBOX 0 FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10 Depression FORMCHECKBOX 0 FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10 Irritability FORMCHECKBOX 0 FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10 Please indicate the frequency of the following symptomsWidespread FORMDROPDOWN Sleep Disturbance FORMDROPDOWN Fatigue FORMDROPDOWN Morning Stiffness FORMDROPDOWN Anxiety FORMDROPDOWN Irritable Bowel Syndrome FORMDROPDOWN Irritable bladder FORMDROPDOWN Headaches FORMDROPDOWN Cold Hands/Feet FORMDROPDOWN Dry Mouth FORMDROPDOWN Depression FORMDROPDOWN Numbness/Tingling FORMDROPDOWN Allergies FORMDROPDOWN Hypoglycemia FORMDROPDOWN Excessive Mucous FORMDROPDOWN Fluid Retention FORMDROPDOWN PMS FORMDROPDOWN Painful Menstruation FORMDROPDOWN Adversely affected by heat or cold FORMDROPDOWN Adversely affected by weather change FORMDROPDOWN Recurring family stress regarding symptoms FORMDROPDOWN Tinnitus Dizziness/Vertigo FORMDROPDOWN Tachycardia FORMDROPDOWN Short-term memory loss FORMDROPDOWN OPIOID RISK TOOLMark each Item Score Item Score box that applies If Female If MaleFemale MaleFamily History of Substance AbuseAlcohol FORMCHECKBOX 13Illegal Drugs FORMCHECKBOX 23Prescription Drugs FORMCHECKBOX 44Personal History of Substance AbuseAlcohol FORMCHECKBOX 33Illegal Drugs FORMCHECKBOX 44Prescription Drugs FORMCHECKBOX 55Age (Mark box if 16 – 45) FORMCHECKBOX 11History of Preadolescent Sexual Abuse FORMCHECKBOX 30Psychological Disease Attention Deficit FORMCHECKBOX 22Disorder,Obsessive CompulsiveDisorder,Bipolar,SchizophreniaDepression FORMCHECKBOX 11TOTAL FORMTEXT ????? FORMTEXT ?????Total Score Risk CategoryLow Risk 0 – 3Moderate Risk 4 – 7High Risk > 8Reference: Webster LR. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool.Pain Medicine. 2005;6(6):432-442. Used with permission.New Clinical Fibromyalgia Diagnostic CriteriaPart 1: Determining Your Widespread Pain Index (WPI)To answer the following questions, patients should take into consideration:how you felt the past week, while taking your current therapies and treatments, andThe WPI Index score from Part 1 is between 0 and 19.exclude your pain or symptoms from other known illnesses such as arthritis, Lupus, Sjogren’s, etc.349250015720200Check each area you have felt pain in over the past week. FORMCHECKBOX Shoulder girdle, left FORMCHECKBOX Lower leg left FORMCHECKBOX Shoulder girdle, right FORMCHECKBOX Lower leg right FORMCHECKBOX Upper arm left FORMCHECKBOX Jaw left FORMCHECKBOX Upper arm, right FORMCHECKBOX Jaw right FORMCHECKBOX Lower arm, left FORMCHECKBOX Chest FORMCHECKBOX Lower arm, right FORMCHECKBOX Abdomen FORMCHECKBOX Hip (buttock) left FORMCHECKBOX Neck FORMCHECKBOX Hip (buttock) right FORMCHECKBOX Upper back FORMCHECKBOX Upper leg left FORMCHECKBOX Lower back FORMCHECKBOX Upper leg right FORMCHECKBOX None of these areasTally your score for Part 1 Widespread Pain Index or WPI and enter here ________Part 2: Symptom Severity Score (SS score):Indicate your level of symptom severity over the past week using the following scale.FatigueWaking unrefreshedCognitive symptoms FORMCHECKBOX 0 = No problem FORMCHECKBOX 1= Slight or mild problems; generally mild or intermittent FORMCHECKBOX 2 = Moderate; considerable problems; often present and/or at a moderate level FORMCHECKBOX 3 = Severe: pervasive, continuous, life disturbing problems FORMCHECKBOX 0= No problem FORMCHECKBOX 1= Slight or mild problems; generally mild or intermittent FORMCHECKBOX 2 = Moderate; considerable problems; often present and/or at a moderate level FORMCHECKBOX 3 = Severe: pervasive, continuous, life disturbing problems FORMCHECKBOX 0= No problem FORMCHECKBOX 1= Slight or mild problems; generally mild or intermittent FORMCHECKBOX 2 = Moderate; considerable problems; often present and/or at a moderate level FORMCHECKBOX 3 = Severe: pervasive, continuous, life disturbing problemsTally your score for Part 2 (not the number of checkmarks) and enter it here ______Part 2a: Symptom Severity Score (SS score):Check each of the following OTHER SYMPTOMS that you have experienced over the past week? FORMCHECKBOX Muscle pain FORMCHECKBOX Irritable bowel syndrome FORMCHECKBOX Fatigue/tiredness FORMCHECKBOX Thinking or remembering problem FORMCHECKBOX Muscle Weakness FORMCHECKBOX Headache FORMCHECKBOX Pain/cramps in abdomen FORMCHECKBOX Numbness/tingling FORMCHECKBOX Dizziness FORMCHECKBOX Insomnia FORMCHECKBOX Depression FORMCHECKBOX Constipation FORMCHECKBOX Pain in upper abdomen FORMCHECKBOX Nausea FORMCHECKBOX Nervousness FORMCHECKBOX Chest pain FORMCHECKBOX Blurred vision FORMCHECKBOX Fever Diarrhea FORMCHECKBOX Dry mouth FORMCHECKBOX Itching FORMCHECKBOX Wheezing FORMCHECKBOX Raynaud’s FORMCHECKBOX Hives/welts FORMCHECKBOX Ringing in ears FORMCHECKBOX Vomiting Heartburn FORMCHECKBOX Oral ulcers FORMCHECKBOX Loss/change in taste FORMCHECKBOX Seizures FORMCHECKBOX Dry eyes FORMCHECKBOX Shortness of breath FORMCHECKBOX Loss of appetite FORMCHECKBOX Rash FORMCHECKBOX Sun sensitivity FORMCHECKBOX Hearing difficulties FORMCHECKBOX Easy bruising FORMCHECKBOX Hair loss FORMCHECKBOX Frequent urination FORMCHECKBOX Painful urination Bladder spasmsCount up the number of symptoms checked above. 0 symptoms…..Give yourself a score of 01 to 10………..Give yourself a score of 111 to 24………Give yourself a score of 225 or more……Give yourself a score of 3Corresponding 2a SCORE: Now add Part 2 AND 2a scores: ____. This is your Symptom Severity Score (SS score), which can range from 0 to 12.Fibromyalgia Network | | (800) 853-2929PHQThis questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question to the best of your ability unless you are requested to skip over a question.1. During the last 4 weeks, how much have you been bothered by any of the following problems? Not Bothered Bothered bothered a little a lota. Stomach pain FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Back pain FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Pain in your arms, legs, or joints (knees, hips, etc.) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Menstrual cramps or other problems with your periods FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Pain or problems during sexual intercourse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Headaches FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX g. Chest pain FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX h. Dizziness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX i. Fainting spells FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX j. Feeling your heart pound or race FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX k. Shortness of breath FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX l. Constipation, loose bowels, or diarrhea FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX m. Nausea, gas, or indigestion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Over the last 2 weeks, how often have you been bothered by any of the following problems?Not at AllSeveral DaysMore than halfNearly every daya. Little interest or pleasure in doing things FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX b. Feeling down, depressed, or hopeless FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Trouble falling or staying asleep, or sleeping too much FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Feeling tired or having little energy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Poor appetite or overeating FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Feeling bad about yourself — or that you are a failure or have let yourself or your family down FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX g. Trouble concentrating on things, such as readingthe newspaper or watching television FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX h. Moving or speaking so slowly that other peoplecould have noticed? Or the opposite — being so fidgetyor restless that you have been movingaround a lot more than usual FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX i. Thoughts that you would be better off deador of hurting yourself in some way FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Questions about anxiety.In the last 4 weeks, have you had an anxiety attack –– NOYESsuddenly feeling fear or panic? FORMCHECKBOX FORMCHECKBOX If you checked NO, go to question #5b. Has this ever happened before? FORMCHECKBOX FORMCHECKBOX c. Do some of these attacks come suddenly out of the blue ––that is, in situations where you don’t expect to be nervous oruncomfortable? FORMCHECKBOX FORMCHECKBOX d. Do these attacks bother you a lot or are you worried abouthaving another attack? FORMCHECKBOX FORMCHECKBOX 4. Think about your last bad anxiety attack. NO YESa. Were you short of breath? FORMCHECKBOX FORMCHECKBOX b. Did your heart race, pound, or skip? FORMCHECKBOX FORMCHECKBOX c. Did you have chest pain or pressure? FORMCHECKBOX FORMCHECKBOX d. Did you sweat? FORMCHECKBOX FORMCHECKBOX e. Did you feel as if you were choking? FORMCHECKBOX FORMCHECKBOX f. Did you have hot flashes or chills? FORMCHECKBOX FORMCHECKBOX g. Did you have nausea or an upset stomach, or the feeling thatyou were going to have diarrhea? FORMCHECKBOX FORMCHECKBOX h. Did you feel dizzy, unsteady, or faint? FORMCHECKBOX FORMCHECKBOX i. Did you have tingling or numbness in parts of your body? FORMCHECKBOX FORMCHECKBOX j. Did you tremble or shake? FORMCHECKBOX FORMCHECKBOX k. Were you afraid you were dying? FORMCHECKBOX FORMCHECKBOX 5. Over the last 4 weeks, how often have you been bothered by Not at all Several More thanany of the following problems? days halfa. Feeling nervous, anxious, on edge, or worrying a lot aboutdifferent things. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX If you checked “Not at all”, go to question #6.If you checked “Not at all”, go to question#6b. Feeling restless so that it is hard to sit still. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX c. Getting tired very easily. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d. Muscle tension, aches, or soreness. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX e. Trouble falling asleep or staying asleep. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX f. Trouble concentrating on things, such as reading a book orwatching TV. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX g. Becoming easily annoyed or irritable. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Questions about eating.NOYESa. Do you often feel that you can’t control what or how much you eat? FORMCHECKBOX FORMCHECKBOX b. Do you often eat, within any 2-hour period, what most peoplewould regard as an unusually large amount of food? FORMCHECKBOX FORMCHECKBOX If you checked “NO” to either #a or #b, got to questions #9c. Has this been as often, on average, as twice a week for the last 3months? FORMCHECKBOX FORMCHECKBOX 7. In the last 3 months have you often done any of the following in order toavoid gaining weight?NOYESa. Made yourself vomit? FORMCHECKBOX FORMCHECKBOX b. Took more than twice the recommended dose of laxatives? FORMCHECKBOX FORMCHECKBOX c. Fasted –– not eaten anything at all for at least 24 hours? FORMCHECKBOX FORMCHECKBOX d. Exercised for more than an hour specifically to avoid gainingweight after binge eating? FORMCHECKBOX FORMCHECKBOX 8. If you checked “YES” to any of these ways of avoiding gaining weight,NOYESwere any as often, on average, as twice a week? FORMCHECKBOX FORMCHECKBOX 9. Do you ever drink alcohol (including beer or wine)? FORMCHECKBOX FORMCHECKBOX If you checked “NO” go to question #11.10. Have any of the following happened to you more than once in the last 6 months?NOYESa. You drank alcohol even though a doctor suggested that you stopdrinking because of a problem with your health. FORMCHECKBOX FORMCHECKBOX b. You drank alcohol, were high from alcohol, or hung over while youwere working, going to school, or taking care of children or otherresponsibilities. FORMCHECKBOX FORMCHECKBOX c. You missed or were late for work, school, or other activitiesbecause you were drinking or hung over. FORMCHECKBOX FORMCHECKBOX d. You had a problem getting along with other people while you weredrinking. FORMCHECKBOX FORMCHECKBOX e. You drove a car after having several drinks or after drinking toomuch. FORMCHECKBOX FORMCHECKBOX 11. If you checked off any problems on this questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not Somewhat Very Extremely at all difficult Difficult Difficult FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.Beck Anxiety ScaleNot at allMildlyModeratelySeverely1. Difficulty breathing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Difficulty sleeping at night FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Dizzy or lightheaded FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Face flushed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Faint FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6.Fear of dying FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Fear of losing control FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Fear of the worst happening FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Feeling hot FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Feelings of choking FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Hands trembling FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Heart pounding or racing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Indigestion or discomfort in abdomen FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Nervous FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Numbness or tingling FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16. On edge FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 17. Racing thoughts FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 18. Shaky FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 19. Sweating (not due to heat) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 20. Terrified FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21. Unable to relax FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 22. Unsteady FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 23. Wobbliness in legs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Over the past month: Check the best answer Never Rarely Occasionally Most Always nights/daysDo you have trouble falling asleep? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Do you have trouble staying asleep? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Do you wake up un-refreshed? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Do you take anything to help you sleep? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Do you use alcohol to help you sleep? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Do you have any medical condition thatdisrupts your sleep? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Have you lost interest in hobbies or activities? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Never Rarely Occasionally Most Always nights/daysDo you feel sad, irritable, or hopeless? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Do you feel nervous or worried? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Do you think something is wrong with your body? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Are you a shift worker or is your sleepschedule irregular? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Are your legs restless and/or uncomfortablebefore bed? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Have you been told that you are restless or that youkick your legs in your sleep? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Do you have any unusual behaviors or movementsduring sleep? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Do you snore? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Has anyone said that you stop breathing, gasp, snort,or choke in your sleep? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Do you have difficulty staying awake during the day? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Has there ever been a period of time when you were not your usual self and... FORMCHECKBOX you felt so good or so hyper that other people thought you were not your normalself or you were so hyper that you got into trouble? FORMCHECKBOX you were so irritable that you shouted at people or started fights or arguments? FORMCHECKBOX you felt much more self-confident than usual? FORMCHECKBOX you got much less sleep than usual and found you didn’t really miss it? FORMCHECKBOX you were much more talkative or spoke much faster than usual? FORMCHECKBOX thoughts raced through your head or you couldn’t slow your mind down? FORMCHECKBOX you were so easily distracted by things around you that you had troubleconcentrating or staying on track? FORMCHECKBOX you had much more energy than usual? FORMCHECKBOX you were much more active or did many more things than usual? FORMCHECKBOX you were much more social or outgoing than usual, for example, you telephonedfriends in the middle of the night? FORMCHECKBOX you were much more interested in sex than usual? FORMCHECKBOX you did things that were unusual for you or that other people might havethought were excessive, foolish, or risky? FORMCHECKBOX spending money got you or your family into trouble?If you checked more than one of the above, have several of these ever happened duringthe same period of time? FORMCHECKBOX YES FORMCHECKBOX NOHow much of a problem did any of these cause you – like being unable to work; havingfamily, money or legal troubles; getting into arguments or fights?Please select one response only FORMCHECKBOX No Problem FORMCHECKBOX Minor Problem FORMCHECKBOX Moderate Problem FORMCHECKBOX Serious ProblemHave any of your blood relatives (i.e. children, siblings, parents, grandparents aunts, uncles)had manic-depressive illness or bipolar disorder? FORMCHECKBOX YES FORMCHECKBOX NOHas a health professional ever told you that you have manic-depressive illness or bipolardisorder? FORMCHECKBOX YES FORMCHECKBOX NO? 2000 by The University of Texas Medical Branch. Reprinted with permission. This instrument is designed forscreening purposes only and is not to be used as a diagnostic tool.RAND36-ItemHealthSurvey1.0QuestionnaireItemsIn general, would you say your health is: FORMCHECKBOX Excellent FORMCHECKBOX Very good FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorCompared to one year ago, how would your rate your health in general now? FORMCHECKBOX Much better now than one year ago FORMCHECKBOX Somewhat better now than one year ago FORMCHECKBOX About thesame FORMCHECKBOX Somewhat worse now than one year ago FORMCHECKBOX Much worse now than one year agoThe following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?(Check One Number on Each Line)YesYesNo, Limited a lotlimited a littleNot limited at allVigorous activities, such as running, liftingheavy objects, participating in strenuous FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX sportsModerate activities, such as moving atable, pushing a vacuum cleaner, bowling, or FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX playing golfLifting or carrying groceries FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Climbing several flights of stairs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Climbing one flight of stairs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Bending, kneeling, or stooping FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Walking more than a mile FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Walking several blocks FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Walking one block FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Bathing or dressing myself FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX During the past 4 weeks, have you had any of the following problems with your work or other regulardaily activities as a result of your physical health? Yes NoCut down the amount of time you spent on work or other activities FORMCHECKBOX FORMCHECKBOX Accomplished less than you would like FORMCHECKBOX FORMCHECKBOX Were limited in the kind of work or other activities FORMCHECKBOX FORMCHECKBOX Had difficulty performing the work or other activities (for example, it took extra effort) FORMCHECKBOX FORMCHECKBOX During the past 4 weeks, have you had any of the following problems with your work or other regulardaily activities as a result of any emotional problems (such as feeling depressed or anxious)? Yes NoCut down the amount of time you spent on work or other activities FORMCHECKBOX FORMCHECKBOX Accomplished less than you would like FORMCHECKBOX FORMCHECKBOX Didn’t do work or other activities as carefully as usual FORMCHECKBOX FORMCHECKBOX During the past 4 weeks to what extent has your physical health or emotional problemsinterfered with your normal social activities with family, friends, neighbors, or groups? FORMCHECKBOX Not at all FORMCHECKBOX Slightly FORMCHECKBOX Moderately FORMCHECKBOX Quite a bit FORMCHECKBOX ExtremelyHow much bodily pain have you had during the past4 weeks? FORMCHECKBOX None FORMCHECKBOX Very mild FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Very severeDuring the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? FORMCHECKBOX Not at all FORMCHECKBOX A little bit FORMCHECKBOX Moderately FORMCHECKBOX Quite a bit FORMCHECKBOX ExtremelyThese questions are about how you feel and how things have been with you during the past 4 weeks.For each question, please give the one answer that comes closest to the way you have been feeling.How much of the time during the past 4 weeks . . .All of Most of A Good Some of A Little None ofthe time the time bit of the the time of the the timetimeDid you feel full of pep? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Have you been a very nervousperson? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Have you felt so down in the dumps andthat nothing could cheer you up? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Have you felt calm and peaceful? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Did you have a lot of energy? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Have you felt down hearted and blue? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Did you feel worn out? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Have you been a happy person? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Did you feel tired? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? FORMCHECKBOX All of the time FORMCHECKBOX Most of the time FORMCHECKBOX Some of the time FORMCHECKBOX A little of the time FORMCHECKBOX None of the timeHow TRUE or FALSE is each of the following statements for you.DefinitelyTrueMostlyTrueDon’tKnowMostlyFalseDefinitelyFalseI seem to get sick a little easier than other people FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX I am as healthy as anybody I know FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX I expect my health to get worse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX My health is excellent FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Email completed form to: intake@1. Ware, J.E., Jr., and Sherbourne, C. D. “The MOS 36-Item Short-Form Health Survey (SF-36): I. Conceptual Framework and item Selection,”Medical Care, 30:473-483, 1992.2. Hays, R.D., & Shapiro, M.F. “An Overview of Generic Health-Related Quality of Life Measures For HIV Research.” Quality of Life Research,1:91-97, 1992.3. Stewart, A. L., Sherbourne, C., Hays, R. D., et al. “Summary and Discussion of MOS Measures,” In A. L. Stewart & J. E. Ware ( eds.),Measuring Functioning and Well-Being: The Medical Outcome Study Approach (pp. 345-371). Durham, NC: Duke University Press, 1992. ................
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