CURRENT COMPLAINTS
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CURRENT COMPLAINTS
Patient’s Name: _______________________ Date: _____________
Please indicate the current complaints you are experiencing by marking the areas on the image below and providing details using the sections that follow.
1. headaches
2. Neck
3. Upper back
4. Mid Back
5. Lower Back
6. Hip
7. Buttock
8. Shoulder
9. Arm
10. Elbow
11. Forearm
12. Wrist
13. Hand
14. Fingers
15. Leg
16. Knee
17. Calf
18. Shin
19. Ankle
20. Foot
21. Toes
22. Chest
23. Ribs
24. Abdomen
25. Pelvis/Groin
|Area of Complaint | |
| |Date of onset:_______________ |
|Location |[pic] Left [pic] Right [pic] Both [pic] Center |
|Pain Ratings |[pic] 0 [pic] 1 [pic] 2 [pic] 3 [pic] 4 [pic] 5 [pic] 6 [pic] 7 [pic] 8 [pic] 9 [pic] 10 (Excruciating) |
|Frequency |[pic] Infrequent < 25% [pic] Occasional 25% to 50% [pic] Frequent 50% to 75% [pic] Constant > 75% |
|Pain Type |[pic] No Pain [pic] Pain [pic] Numbness [pic] Tingling [pic] Muscle Spasms [pic] Burning |
|Severity | [pic] Mild [pic] Mild to Moderate [pic] Moderate [pic] Moderate to Severe [pic] Severe |
|What makes it better? | [pic] Medication [pic] Lying Down [pic] Standing [pic] Sitting [pic] Stretching [pic] Range of Motion [pic] Nothing |
|What makes it worse? |[pic] Brig [pic] Movements [pic] Bending [pic] Twisting [pic] Weight Bearing [pic] Movements |
| |[pic] Wat [pic] Neck flexion [pic] Sneezing [pic] Sitting [pic] Standing [pic] Walking |
| |[pic] Chewing [pic] Yawning [pic] Opening mouth [pic] Closing mouth |
| |[pic] Range of motion [pic] pushing/pulling [pic] Lifting |
| |[pic] Watching T.V. [pic] Reading [pic] Working [pic] Driving [pic] Housework |
| |[pic] Bright lights [pic] Loud Noises |
|Does the pain |Upper Body |[pic] Nec [pic] Head [pic] Forehead [pic] Back of head [pic] Right side of head [pic] Left side of head |
|radiate to any | |[pic] Neck [pic] Right Ear [pic] Left Ear [pic] Right Eye [pic] Left Eye |
|other locations? | |[pic] Face [pic] Right Jaw [pic] Left Jaw |
| | |[pic] Right Upper back [pic] Left Upper back [pic] Right Shoulder [pic] Left Shoulder |
| | |[pic] Right Chest [pic] Left Chest [pic] Right Ribs [pic] Left Ribs |
| |Mid Body | [pic] Right Mid back [pic] Left Mid back [pic] Right Lower back [pic] Left Lower back |
| | |[pic] Right Hip [pic] Left Hip [pic] Right Buttock [pic] Left Buttock [pic] Groin |
| | |[pic] Right Arm [pic] Left Arm [pic] Right forearm [pic] Left forearm |
| | |[pic] Right hand [pic] Left hand [pic] Right fingers [pic] Left fingers |
| |Lower Body | [pic] Right Thigh [pic] Left Thigh [pic] Right Knee [pic] Left Knee |
| | |[pic] Right Calf [pic] Left Calf [pic] Right Toes [pic] Left Toes |
| | |[pic] Right Foot [pic] Left Foot [pic] Right Toes [pic] Left Toes |
|Described as | [pic] Aching [pic] Dull [pic] Sharp [pic] Stabbing [pic] Throbbing |
|At it’s worst | [pic] Morning [pic] Afternoon [pic] Evening [pic] Night After Activities: [pic] Light [pic] |
| |Moderate |
|Associated with |[pic] Dizz [pic] Dizziness [pic] Nausea [pic] Visual Problems [pic] Ringing/Buzzing ears |
| |[pic] Bright light [pic] Sensitivity [pic] Loss of balance |
|Comments | |
| | |
| | |
| | |
|Area of Complaint | |
| |Date of onset:______________ |
|Location |[pic] Left [pic] Right [pic] Both [pic] Center |
|Pain Ratings |[pic] 0 [pic] 1 [pic] 2 [pic] 3 [pic] 4 [pic] 5 [pic] 6 [pic] 7 [pic] 8 [pic] 9 [pic] 10 (Excruciating) |
|Frequency |[pic] Infrequent < 25% [pic] Occasional 25% to 50% [pic] Frequent 50% to 75% [pic] Constant > 75% |
|Pain Type |[pic] No Pain [pic] Pain [pic] Numbness [pic] Tingling [pic] Muscle Spasms [pic] Burning |
|Severity | [pic] Mild [pic] Mild to Moderate [pic] Moderate [pic] Moderate to Severe [pic] Severe |
|What makes it better? | [pic] Medication [pic] Lying Down [pic] Standing [pic] Sitting [pic] Stretching [pic] Range of Motion [pic] Nothing |
|What makes it worse? |[pic] Brig [pic] Movements [pic] Bending [pic] Twisting [pic] Weight Bearing [pic] Movements |
| |[pic] Wat [pic] Neck flexion [pic] Sneezing [pic] Sitting [pic] Standing [pic] Walking |
| |[pic] Chewing [pic] Yawning [pic] Opening mouth [pic] Closing mouth |
| |[pic] Range of motion [pic] pushing/pulling [pic] Lifting [pic] Bright lights [pic] Loud Noises |
| |[pic] Watching T.V. [pic] Reading [pic] Working [pic] Driving [pic] Housework |
|Does the pain |Upper Body |[pic] Nec [pic] Head [pic] Forehead [pic] Back of head [pic] Right side of head [pic] Left side of head |
|radiate to any | |[pic] Neck [pic] Right Ear [pic] Left Ear [pic] Right Eye [pic] Left Eye |
|other locations? | |[pic] Face [pic] Right Jaw [pic] Left Jaw |
| | |[pic] Right Upper back [pic] Left Upper back [pic] Right Shoulder [pic] Left Shoulder |
| | |[pic] Right Chest [pic] Left Chest [pic] Right Ribs [pic] Left Ribs |
| |Mid Body | [pic] Right Mid back [pic] Left Mid back [pic] Right Lower back [pic] Left Lower back |
| | |[pic] Right Hip [pic] Left Hip [pic] Right Buttock [pic] Left Buttock [pic] Groin |
| | |[pic] Right Arm [pic] Left Arm [pic] Right forearm [pic] Left forearm |
| | |[pic] Right hand [pic] Left hand [pic] Right fingers [pic] Left fingers |
| |Lower Body | [pic] Right Thigh [pic] Left Thigh [pic] Right Knee [pic] Left Knee |
| | |[pic] Right Calf [pic] Left Calf [pic] Right Toes [pic] Left Toes |
| | |[pic] Right Foot [pic] Left Foot [pic] Right Toes [pic] Left Toes |
|Described as | [pic] Aching [pic] Dull [pic] Sharp [pic] Stabbing [pic] Throbbing |
|At it’s worst | [pic] Morning [pic] Afternoon [pic] Evening [pic] Night After Activities: [pic] Light [pic] |
| |Moderate |
|Associated with |[pic] Dizz [pic] Dizziness [pic] Nausea [pic] Visual Problems [pic] Ringing/Buzzing ears |
| |[pic] Bright light [pic] Sensitivity [pic] Loss of balance |
|Comments | |
| | |
|Area of Complaint | |
| |Date of onset:______________ |
|Location |[pic] Left [pic] Right [pic] Both [pic] Center |
|Pain Ratings |[pic] 0 [pic] 1 [pic] 2 [pic] 3 [pic] 4 [pic] 5 [pic] 6 [pic] 7 [pic] 8 [pic] 9 [pic] 10 (Excruciating) |
|Frequency |[pic] Infrequent < 25% [pic] Occasional 25% to 50% [pic] Frequent 50% to 75% [pic] Constant > 75% |
|Pain Type |[pic] No Pain [pic] Pain [pic] Numbness [pic] Tingling [pic] Muscle Spasms [pic] Burning |
|Severity | [pic] Mild [pic] Mild to Moderate [pic] Moderate [pic] Moderate to Severe [pic] Severe |
|What makes it better? | [pic] Medication [pic] Lying Down [pic] Standing [pic] Sitting [pic] Stretching [pic] Range of Motion [pic] Nothing |
|What makes it worse? |[pic] Brig [pic] Movements [pic] Bending [pic] Twisting [pic] Weight Bearing [pic] Movements |
| |[pic] Wat [pic] Neck flexion [pic] Sneezing [pic] Sitting [pic] Standing [pic] Walking |
| |[pic] Chewing [pic] Yawning [pic] Opening mouth [pic] Closing mouth |
| |[pic] Range of motion [pic] pushing/pulling [pic] Lifting [pic] Bright lights [pic] Loud Noises |
| |[pic] Watching T.V. [pic] Reading [pic] Working [pic] Driving [pic] Housework |
|Does the pain |Upper Body |[pic] Nec [pic] Head [pic] Forehead [pic] Back of head [pic] Right side of head [pic] Left side of head |
|radiate to any | |[pic] Neck [pic] Right Ear [pic] Left Ear [pic] Right Eye [pic] Left Eye |
|other locations? | |[pic] Face [pic] Right Jaw [pic] Left Jaw |
| | |[pic] Right Upper back [pic] Left Upper back [pic] Right Shoulder [pic] Left Shoulder |
| | |[pic] Right Chest [pic] Left Chest [pic] Right Ribs [pic] Left Ribs |
| |Mid Body | [pic] Right Mid back [pic] Left Mid back [pic] Right Lower back [pic] Left Lower back |
| | |[pic] Right Hip [pic] Left Hip [pic] Right Buttock [pic] Left Buttock [pic] Groin |
| | |[pic] Right Arm [pic] Left Arm [pic] Right forearm [pic] Left forearm |
| | |[pic] Right hand [pic] Left hand [pic] Right fingers [pic] Left fingers |
| |Lower Body | [pic] Right Thigh [pic] Left Thigh [pic] Right Knee [pic] Left Knee |
| | |[pic] Right Calf [pic] Left Calf [pic] Right Toes [pic] Left Toes |
| | |[pic] Right Foot [pic] Left Foot [pic] Right Toes [pic] Left Toes |
|Described as | [pic] Aching [pic] Dull [pic] Sharp [pic] Stabbing [pic] Throbbing |
|At it’s worst | [pic] Morning [pic] Afternoon [pic] Evening [pic] Night After Activities: [pic] Light [pic] |
| |Moderate |
|Associated with |[pic] Dizz [pic] Dizziness [pic] Nausea [pic] Visual Problems [pic] Ringing/Buzzing ears |
| |[pic] Bright light [pic] Sensitivity [pic] Loss of balance |
|Comments | |
________________________________________________ Signature[pic]
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Office Financial Policy
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