OPTUM QUESTIONNAIRE

Full Name/Participant’s Name:

First NameLast Name

Email

example@example.com

Symptoms began on:

Date

Briefly describe your symptoms

How did your symptoms start?

Average pain / symptom intensity:

no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain

Last 24 hours

Past week

How often do you experience your symptoms?

How much have your symptoms interfered with your daily activities?

How is your condition changing, since care at this facility?

In general, would you say your overall health right now is...

Back Screening Tool (if applicable)

Annotate Image

Has your back pain spread down your leg(s) at some time in the last 2 weeks?

Have you had pain in the shoulder or neck at some time in the last 2 weeks?

Have you only walked short distances because of your back pain?

In the last 2 weeks, have you dressed more slowly than usual because of back pain?

Do you think it’s not really safe for a person with a condition like your to be physically active?

Have worrying thoughts been going through your mind a lot of time?

Do you feel that your back pain is terrible and its never going to get any better?

In general, have you stopped enjoying all the things you usually enjoy?

Overall, how bothersome has your back pain been in the last 2 weeks?

Date

Patient Signature:

Please affix your signature inside the box

p. 443.979.7171

AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170 Columbia, MD 21046

f. 667.200.5908