Patient Questionnaire

* Denotes Required Field.

Your Full Name: * (Last, First, Middle Initial )
Current Marital Status: *



1. When did your present episode of pain begin? 

2. Describe the pain in your own words.

3. What makes it worse ?

4. What makes it better?



5. Check to describe the pattern of your pain.

6. Check which best describes the type of pain.

7. On a scale of 0-10, 0 represents no pain and 10 the very worst……

How would you score your pain today?

What is your daily average pain?

How would you score your worst pain from this injury?

8. Please mark the areas on your body where you feel the described sensations:

This will be completed when you arrive.


9. Are you allergic to any medications?
If so, list:

10. Do you smoke?
If yes, number of packs per day:

11. Do you drink alcoholic beverages?
How may drinks per day: , or per week



Height: Weight:

12. Have you ever had any of the following? (check all that apply)

13. Have you had any surgeries?

Please list operations and approximate dates:



14. What is your occupation?

15. Are you working now?

16. If not currently working, how long have you been off work?

17. Are you currently receiving Workers’ Compensation (disability income)?

18. Are you currently in the process of trying to obtain compensation
(disability benefits)?

19. Are you involved in any litigation (are you suing anyone) related to your pain?

20. Have you had to be off work for pain problems in the past?
For how long?



21. Click the one number that describes how, during the past 24 hours, pain has interfered with your:
"0" = Does Not Interfere   "10" = Completely Interferes
A. General Activity

B. Mood

C. Walking ability

D. Normal work (includes both work outside the home and housework)

E. Relations with other people

F. Sleep

G. Enjoyment of life


Your Email (required)


8/09 #623650