OPTUM Page 1

OPTUM Page 1

This is a required form for United Healthcare Patients only.
Name*

First NameLast Name
Date Symptoms Began*

MonthDayYear
Please give an estimated date if you do not have exact.
Briefly Describe your Symptoms:*
How did your Symptoms start:*
Average Pain Intensity:*
Average Pain in last 24 hours
Average Pain Intensity:*
Average pain over the last week.
How often do you experience your symptoms:*

Constantly (76%-100% of the time)Frequently (51%-75% of the time)Occasionally (26%-50% of the time)Intermittently (0%-25% of the time)
How much have your symptoms interfered with daily activity:*

Not at allA little bitModeratleyQuite a bitExtremely
How is your condition changing since care began at this facility*

N/A - This is initial visitMuch worseWorseA little worseNo changeA little betterBetterMuch better
In general, would you say your overall health is :*

ExcellentVery GoodGoodFairPoor
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: