Name:

DOB:

 

Please describe your pain and how it started?

 

Please describe your pain: (Sharp/Dull, deep/surface)

 

How often is the pain there? (Constantly, intermittently, occasionally)

 

On a scale of 0-10, 10 being the worst imaginable pain and 0 being no pain at all)

         What would you score your pain at its worst?

         What would you score your pain most of the time?

 

What makes the pain worse?

 

What makes the pain easier?

 

Is the pain worse at any point during the day?

 

General Health:

 Have you had any recent unexplained weight loss?

 Do you have Diabetes? Which Type?

 Do you have Rheumatoid Arthritis (Year of diagnosis)?

 Do you have osteoporosis (thinning of the bones)?

 Do you have any heart or lung problems?

 Do you have epilepsy?

 Have you had Cancer or treatment for Cancer?

 Have you taken any steroids?

 Do you take anything to thin your blood?

 Have you had any X-Rays or Scans for your problem area?

 Have you had any recent surgery? in the last 3 months?

 Do you suffer a constant and unchanging pain?

 Do you smoke?

 

Do you take any medication? (Please state)

 

Are you interested in a particular treatment?

Acupuncture ☐

Ultrasound ☐

Interferential ☐

Shockwave ☐

Manipulation ☐

Wax Bath ☐