MVA, VA, Other Incident: Complaints & ADL

Basic Information

Have you been to DREAM Wellness prior to today for this complaint?*

No, this is my first visit at DREAM WellnessYes, this is a follow up visitI have been to DREAM Wellness before, but this is a new injury / incidentOther

Name of person receiving care:*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Date of Birth*

MonthDayYear

Date of Injury/Onset:

Date

Dominant Hand*

LeftRightBoth

Insurance Information if applicable (include policy number and claim number)

Description of Accident/Injury/Onset

During and after accident details

Enter details of your condition during and after the injury / onset

Are your current complaints the result of an automobile accident?*

YesNo

Automobile Accident Details and Description

Your Vehicle Type:*

Approximate time of accident*

:HourMinutesAM/PM Option

Approximate speed of your vehicle at time of impact*

Approximate speed of the other vehicle if known and applicable

Damage to your vehicle*

MildModerateTotaledUnsure

What was your vehicle doing at time of accident?*

Visibility at the time of accident:*

GoodFairPoor

Road conditions at time of accident: (Choose all that apply)*

Point of Impact: (Choose all that apply)*

Who hit who/what?*

You hit other vehicleOther vehicle hit youOther

Additional Accident Information

Is there anything else we should know about the details of this accident?

During the Accident:

Did you see the accident coming?*

YesNo

Were you braced for the impact?*

YesNo

Were you wearing a shoulder/lap seat belt?*

YesNo

Did the driver's front airbag deploy?*

YesNo

Did passenger front airbag deploy?*

YesNo

Did any side airbags deploy?*

YesNo

Your headrest position?*

What was the direction of your head at the time of impact?*

Any other information you recall about body position...

Which way was your body thrown, etc...

Did your body strike the inside of your vehicle?*

YesNoUnsure

Describe

Did you lose consciousness during the injury?*

YesNoUnsure

For how long were you unconscious?

Your vehicle's estimated damage (if known):

Damage to other vehicle if applicable:

MildModerateTotaledUnknown

Did police show up at the scene?*

YesNoNot sure

Was an accident report filled out?*

YesNoNot sure

Where did you go immediately from the scene of the accident?*

How did you get there?*

Since the accident, have X-Rays been taken?*

YesNo

What body parts were X-rayed?

What did the X-rays reveal if known?

Since the accident, was lab work done?*

YesNo

What lab work?

Following the accident, were you given...

Cervical CollarIceBack BraceOther

What medications (if any) did you take?

What follow-up instructions were you given?

Check any of the symptoms you experienced right after and/or within a few days following the accident*

What other symptoms did you experience since the accident?

Historical Information

Prior Similar Symptoms:

I have NOT had prior similar symptoms to current complaintsMy current complaints DID exist before, but had been dormantMy current complaints ALREADY existed and worsenedOther

Has your history contributed to your symptoms?

My history HAS contributed to my current symptoms.My history HAS NOT contributed to my current symptomsI'm NOT SURE if my history has contributed to my symptomsOther

My most recent prior similar symptoms (if applicable)

Tell us about similar symptoms in the past and how long ago they occurred

Medical History Section:

Enter additional medical historical data here

Medications History Section:

Enter any medications historical data here

Family History Section

Enter relevant familial history here

Additional Historical Information Section

Summarize other treatments that were received here

Surgical Historical Section:

Enter any surgical history here

Occupational History Section:

Enter occupational history, such as lost work etc...

Social History Section:

Enter any relevant social history here

Prior Treatment Section:

Summarize past treatments received here

Have you seen any other healthcare providers for this complaint prior to visiting DREAM Wellness?*

YesNo

Prior Care / Treatment for this complaint

If you have seen other healthcare providers for this complaint, enter the information below:

Treatment History 1:

Doctor's name

Specialty

First Visit Date

Last Visit Date

Type of care received? How many treatments did you receive? Was it helpful? Are you still seeing the provider?

Treatment History 2:

Doctor's name

Specialty

First Visit Date

Last Visit Date

Type of care received? How many treatments did you receive? Was it helpful? Are you still seeing the provider?

Treatment History 3:

Doctor's name

Specialty

First Visit Date

Last Visit Date

Type of care received? How many treatments did you receive? Was it helpful? Are you still seeing the provider?

Today's Date (Date of follow up visit)*

Date

Location of pain today (check all that apply)*

Are your headaches on the... (check all that apply)*

How would you describe the headaches? (Choose all that apply)*

Headache Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the head pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the head pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Head Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect your head pain and how? (Only complete if necessary)

Heachace Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on headaches:

How would you describe the jaw pain? (Choose all that apply)*

Jaw Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the jaw pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the jaw pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Jaw Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect your jaw pain and how? (Only complete if necessary)

Jaw Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the jaw pain:

Which eye hurts?*

LeftRightBoth

How would you describe the eye pain? (Choose all that apply)*

Eye Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the eye pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the eye pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Eye Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect your eye pain and how? (Only complete if necessary)

Eye Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the eye pain:

Where does your neck hurt? (Choose all that apply)*

How would you describe the neck pain? (Choose all that apply)*

Neck Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the neck pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the neck pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Neck Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect your neck pain and how? (Only complete if necessary)

Neck Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the neck pain:

Does your upper back hurt on the... (check all that apply)*

Left sideRight sideBothOther

How would you describe the upper back pain? (Choose all that apply)*

Upper Back Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the upper back pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the upper back pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Upper Back Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect your upper back pain and how? (Only complete if necessary)

Upper Back Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on upper back pain:

Does your mid back hurt on the... (check all that apply)*

Left sideRight sideBothOther

How would you describe the mid back pain? (Choose all that apply)*

Mid Back Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the mid back pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the mid back pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Mid Back Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect your mid back pain and how? (Only complete if necessary)

Mid Back Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on mid back pain:

Does your low back hurt on the... (check all that apply)*

Left sideRight sideBothOther

How would you describe the low back pain? (Choose all that apply)*

Low Back Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the low back pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the low back pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Low Back Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect your low back pain and how? (Only complete if necessary)

Low Back Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the low back pain:

Where does your chest hurt... (check all that apply)*

Left sideRight sideBothOther

How would you describe the chest pain? (Choose all that apply)*

Chest Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the chest pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the chest pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Chest Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect your chest pain and how? (Only complete if necessary)

Chest Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the chest pain:

Describe the location of your abdominal pain*

How would you describe the abdominal pain? (Choose all that apply)*

Abdominal Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does this abdominal pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the abdominal pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Abdominal Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the abdominal pain and how? (Only complete if necessary)

Abdominal Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the abdominal pain:

Describe the location of your rib pain*

How would you describe the rib pain? (Choose all that apply)*

Rib Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does this rib pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the rib pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Rib Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the rib pain and how? (Only complete if necessary)

Rib Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the rib pain:

Does your buttocks hurt on the... (check all that apply)*

Left sideRight sideBothOther

How would you describe the buttocks pain? (Choose all that apply)*

Buttocks Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the buttocks pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the buttocks pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Buttocks Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the buttocks pain and how? (Only complete if necessary)

Buttocks Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the buttocks:

Which shoulder hurts? (Check all that apply)*

LeftRightBothOther

How would you describe the shoulder pain? (Choose all that apply)*

Shoulder Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the shoulder pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the shoulder pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Shoulder Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the shoulder pain and how? (Only complete if necessary)

Shoulder Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the shoulder pain:

Which upper arm hurts? (Check all that apply)*

LeftRightBothOther

How would you describe the upper arm pain? (Choose all that apply)*

Upper Arm Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the upper arm pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the upper arm pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Upper Arm Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the upper arm pain and how? (Only complete if necessary)

Upper Arm Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the upper arm pain:

Which hand hurts? (Check all that apply)*

LeftRightBothOther

How would you describe the hand pain? (Choose all that apply)*

Hand Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the hand pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the hand pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Hand Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the hand pain and how? (Only complete if necessary)

Hand Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the hand pain:

Which wrist hurts? (Check all that apply)*

LeftRightBothOther

How would you describe the wrist pain? (Choose all that apply)*

Wrist Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the wrist pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the wrist pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Wrist Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the wrist pain and how? (Only complete if necessary)

Wrist Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the wrist pain:

Which hip hurts? (Check all that apply)*

LeftRightBothOther

How would you describe the hip pain? (Choose all that apply)*

Hip Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the hip pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the hip pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Hip Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the hip pain and how? (Only complete if necessary)

Hip Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the hip pain:

Which leg hurts? (Check all that apply)*

LeftRightBothOther

How would you describe the leg pain? (Choose all that apply)*

Leg Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the leg pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the leg pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Leg Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the leg pain and how? (Only complete if necessary)

Leg Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the leg pain:

Which knee hurts? (Check all that apply)*

LeftRightBothOther

How would you describe the knee pain? (Choose all that apply)*

Knee Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the knee pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the knee pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Knee Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the knee pain and how? (Only complete if necessary)

Knee Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the knee pain:

Which foot hurts? (Check all that apply)*

LeftRightBothOther

How would you describe the foot pain? (Choose all that apply)*

Foot Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the foot pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the foot pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Foot Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the foot pain and how? (Only complete if necessary)

Foot Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the foot pain:

What is the "other" location of pain?*

Which side if applicable? (Check all that apply)*

How would you describe the pain? (Choose all that apply)*

Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does this pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect your pain and how? (Only complete if necessary)

Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on above symptom

Which forearm hurts? (Check all that apply)*

LeftRightBothOther

How would you describe the forearm pain? (Choose all that apply)*

Forearm Pain Frequency*

Up to 1/4 of awake time1/4 to 1/2 of awake time1/2 to 3/4 of awake timeMost of the time

Does the forearm pain radiate to... (choose all that may be applicable or leave blank if none are applicable)

	Left Side	Right Side	Both Sides
Head
Neck
Shoulder
Arm
Hip
Leg
Foot

Other body parts that the forearm pain radiates to... (leave blank if not applicable)

Times & Actions Affecting the Forearm Pain*

	Brings it on	Aggravates it	Relieves it	No impact
In the A.M.
In the P.M.
Bending Forward
Bending Backward
Bending Left
Bending Right
Twisting Left
Twisting Right
Coughing
Sneezing
Straining
Standing
Sitting
Lifting

What other actions affect the forearm pain and how? (Only complete if necessary)

Forearm Pain Intensity*

Does NOT affect daily activitiesSomewhat affects daily activitiesSeriously affects daily activitiesPrevents daily activities

Additional Data on the forearm pain:

Is today's visit a routine visit or examination (first exam or re-exam)?*

Today is my first visitToday is a re-examinationToday is a follow up visit / adjustmentI'm not sure

	I can do it without any difficulty	I can do it without much difficulty, despite some pain	I manage to do it by myself, despite marked pain	I manage to do it, despite the pain but only if I have help	I cannot do it at all, because of the pain
Bathing
Drying hair
Brushing teeth
Putting on shoes
Preparing meals
Taking out trash
Showering
Combing hair
Making bed
Tying shoes
Eating
Doing laundry
Washing hair
Washing face
Putting on shirt
Putting on pants
Cleaning dishes
Going to toilet

	I can do it without any difficulty	I can do it without much difficulty, despite some pain	I manage to do it by myself, despite marked pain	I manage to do it, despite the pain but only if I have help	I cannot do it at all, because of the pain
Standing
Walking
Kneeling
Bending backward
Twisting left
Leaning back
Sitting
Stooping
Reaching
Bending left
Twisting right
Leaning left
Reclining
Squatting
Bending forward
Bending right
Leaning forward
Leaning right
Standing for long periods
Sitting for long periods
Walking for long periods
Kneeling for long periods

	I can do it without any difficulty	I can do it without much difficulty, despite some pain	I manage to do it by myself, despite marked pain	I manage to do it, despite the pain but only if I have help	I cannot do it at all, because of the pain
Carrying small objects
Lifting weights off floor
Pushing things while seated
Exercising upper body
Carrying large objects
Lifting weights off table
Pushing things while standing
Exercising lower body
Carrying brief case
Climbing stairs
Pulling things while seated
Exercising arms
Carrying large purse
clinging inclines
Pulling things while standing
Exercising legs

	I can do it without any difficulty	I can do it without much difficulty, despite some pain	I manage to do it by myself, despite marked pain	I manage to do it, despite the pain but only if I have help	I cannot do it at all, because of the pain
Bowling
Jogging
Swimming
Ice skating
Competitive sports
Dating
Golfing
Dancing
Skiing
Roller skating
Hobbies
Dining out
Carrying large purse
climbing inclines
Pulling things while standing
Exercising legs

	I can do it without any difficulty	I can do it without much difficulty, despite some pain	I manage to do it by myself, despite marked pain	I manage to do it, despite the pain but only if I have help	I cannot do it at all, because of the pain
Driving a motor vehicle
As a passenger in a motor vehicle
As a passenger on a train or bus
Driving for long periods of time
As an airline passenger

	This area is not affected by my condition	This area is slightly affected by my condition	My condition moderately restricts my ability in this area	My condition seriously limits my ability in this area	My condition prevents me from using this ability
Concentrating
Hearing
Listening
Speaking
Reading
Writing
Using a keyboard

	This area is not affected by my condition	This area is slightly affected by my condition	My condition moderately restricts my ability in this area	My condition seriously limits my ability in this area	My condition prevents me from using this ability
Grasping
Holding
Pinching
Percussive movements
Sensory discrimination

	This area is not affected by my condition	This area is slightly affected by my condition	My condition moderately restricts my ability in this area	My condition seriously limits my ability in this area	My condition prevents me from using this ability
Ability for a normal, restful nights sleep
Ability to participate in desired sexual activity