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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