Russell Chiropractic



Pain Intensity?No Pain ?Mild Pain ?Moderate Pain ?Severe Pain ?Worst Possible PainSleeping?Perfect ?Mildly ?Moderately ?Greatly Disturbed ?Totally Disturbed Sleep Disturbed sleep Disturbed sleep Sleep SleepPersonal Care [washing, dressing etc.]?No Pain; ?Mild pain; ?Moderate pain; ?Moderate Pain; ?Severe Pain; need (no restrictions) (no restrictions) (need to go slowly) (need some assistance) (100% assistance)Travel [ driving, etc.]?No Pain ?Mild Pain ?Moderate Pain ?Moderate Pain ?Severe Painon long trips on long trips on long trips on short trips on short tripsWork?Can do usual work; ?Can do usual work; ?Can do 50% ?Can do 25% ?CannotUnlimited, extra work no extra work of usual work of usual work workRecreation?Can do all ?Can do most ?Can do some ?Can do a few ?Cannot do any Activities activities activities activities activitiesFrequency of pain?No ?Occasional pain; ?Intermittent pain; ?Frequent pain; ?Constant painPain 25% of the day 50% of the day 75% of the day 100% of the dayLifting?No pain with ?Increased pain ?Increased pain w/ ?Increased pain ?Increased painheavy weight w/ heavy weight moderate weight w/light weight with any weightWalking?No Pain at ?Increased pain ?Increased pain ?Increased pain ?Increased painany distance after 1 mile after 1/2 mile after 1/4 mile with all walkingStanding?No pain after ?Increased pain ?Increased pain ?Increased pain ?Increased painseveral hours after several hours after 1 hour after 1/2 hour with any standingSignature ________________________________________ Date ______________________ ................
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