Patient Data Sheet

  • Personal Information
  • Pain Synopsis
  • Personal Health Information
  • Case History

Personal Information


cm
ft
in
kg
lb
cm
in

Pain Synopsis


Lower Back Pain Levels

When you have the least amount of pain, what number would that be between 0 (no pain) and 10 (constant extreme pain)?
0
When you have the most amount of pain, what number would that be between 0 (no pain) and 10 (constant extreme pain)?
0
Rate your average pain (i.e. 20 days of the month, you have a Minimum (2) pain, but 10 days of the month you have a Maximum (9) pain, therefore the Average pain may be closer to the Minimum than to the Maximum, giving you an Average of possibly (4))
0

Neck Pain Levels

When you have the least amount of pain, what number would that be between 0 (no pain) and 10 (constant extreme pain)?
0
When you have the most amount of pain, what number would that be between 0 (no pain) and 10 (constant extreme pain)?
0
Rate your average pain (i.e. 20 days of the month, you have a Minimum (2) pain, but 10 days of the month you have a Maximum (9) pain, therefore the Average pain may be closer to the Minimum than to the Maximum, giving you an Average of possibly (4))
0

Tolerances / Endurance (maximum time / distance)

Personal Health Information


Pictures and incision measurements may be required at a later time.

Case History - Work Involvement & Leisure Time Activities

The physical strain in job and leisure time plays a major role for orthopedic diagnosis and therapy. This questionnaire will therefore help us to give you a proper evaluation.