PATIENT SYMPTOM HISTORY - Injury & Pain Center
PATIENT SYMPTOM HISTORY
Circle what describes your pain.
Neck Pain is: constant –or– comes & goes; worse on the right, left, upper, lower, middle.
What makes the pain better? Rest, sleeping, sitting, pain medication, certain movements, certain activities
What makes the pain worse? Bending, lifting, twisting, sitting, work, certain movements, certain activities
The pain is: sharp, dull, tired, tight, tender, pressure-like, muscle-type, achy, other___________
The pain: radiates, is in one place, difficult to locate, other_____________________________________
It is worse: at night, during the day, getting up, after work, all the time, other_______________________
______________________________________________________________________________________
Middle Back Pain is: constant –or– comes & goes; worse on the right, left, upper, lower, middle.
What makes the pain better? Rest, sleeping, sitting, pain medication, certain movements, certain activities
What makes the pain worse? Bending, lifting, twisting, sitting, work, certain movements, certain activities
The pain is: sharp, dull, tired, tight, tender, pressure-like, muscle-type, achy, other___________
The pain: radiates, is in one place, difficult to locate, other_______________________________
It is worse: at night, during the day, getting up, after work, all the time, other_______________________
_______________________________________________________________________________________
Lower Back Pain is: constant –or– comes & goes; worse on the right, left, upper, lower, middle.
What makes the pain better? Rest, sleeping, sitting, pain medication, certain movements, certain activities
What makes the pain worse? Bending, lifting, twisting, sitting, work, certain movements, certain activities
The pain is: sharp, dull, tired, tight, tender, pressure-like, muscle-type, achy, other____________
The pain: radiates, is in one place, difficult to locate, other______________________________________
It is worse: at night, during the day, getting up, after work, all the time, other________________________
_______________________________________________________________________________________
Headache is: constant –or– comes & goes; worse on the right, left, front, rear, all over.
What makes the pain better? Rest, sleeping, sitting, pain medication, certain movements, certain activities
What makes the pain worse? Bending, lifting, twisting, sitting, work, certain movements, certain activities
The pain is: sharp, dull, tired, tight, tender, pressure-like, muscle-type, achy, other___________
The pain lasts: _______ minutes, _______ hours, or is constant until I __________________________
It is worse: at night, during the day, getting up, after work, all the time____________________________
Patient Name Date ___/___/___ Date of Injury___/___/___
Revised: 2-9-2012
PATIENT SYMPTOM HISTORY
[CIRCLE ALL THAT APPLY]
Shoulder, Arm or Hand Pain is: constant –or– comes & goes; worse on the right, left, upper, lower.
What makes the pain better? Rest, sleeping, sitting, pain medication, certain movements, certain activities
What makes the pain worse? Bending, lifting, twisting, sitting, work, certain movements, certain activities
The pain is: sharp, dull, tired, tight, tender, pressure-like, muscle-type, achy, other
The pain: radiates, is in one place, difficult to locate, other
It is worse: at night, during the day, getting up, after work, all the time, other
Leg, Knee or Ankle Pain is: constant –or– comes & goes; worse on the right, left, upper, lower.
What makes the pain better? Rest, sleeping, sitting, pain medication, certain movements, certain activities
What makes the pain worse? Bending, lifting, twisting, sitting, work, certain movements, certain activities
The pain is: sharp, dull, tired, tight, tender, pressure-like, muscle-type, achy, other
The pain: radiates, is in one place, difficult to locate, other
It is worse: at night, during the day, getting up, after work, all the time, other
Patient Name Date ___/___/___ Date of Injury___/___/___
Revised 2-9-2012
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Draw in your pain area.
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