OPTUM Page 1
This is a required form for United Healthcare Patients only.
Name
*
First Name
Last Name
Date Symptoms Began
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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 all
A little bit
Moderatley
Quite a bit
Extremely
How is your condition changing since care began at this facility
*
N/A - This is initial visit
Much worse
Worse
A little worse
No change
A little better
Better
Much better
In general, would you say your overall health is :
*
Excellent
Very Good
Good
Fair
Poor
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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