portlandmichiro.com - Case Questionnaire

CASE QUESTIONNAIRE
Name:

First NameLast Name
1. Select the severity (0 = No Pain to 10 = Very Severe Pain) and Frequency of pain (% of the week you experience the pain)
a. Condition / Problem
Severity

0

1

2

3

4

5

6

7

8

9

10

0 is Minimal, 10 is Severe
Frequency (% of week) {0= Occasional, 100= Constant}
b. Condition / Problem
Severity

0

1

2

3

4

5

6

7

8

9

10

0 is Minimal, 10 is Severe
Frequency (% of week) {0= Occasional, 100= Constant}
c. Condition / Problem
Severity

0

1

2

3

4

5

6

7

8

9

10

0 is Minimal, 10 is Severe
Frequency (% of week) {0= Occasional, 100= Constant}
Please mark the figures where you experience pain.
2. Symptoms are worse in the (circle what applies)
3. Symptom (a.) is:
4. Symptom (b.) is:
5. When did your symptoms begin (onset date)?

MonthDayYear
Date
6. How did your symptoms begin?
7. Have you experienced these before?
8. Do your symptoms radiate?
9. Has your condition?
10. Select the things that make your problems worse:
11. Is there anything you can do to relieve the problems?
If yes, describe:
If No, what have you tried that has not helped?
12. Have you been treated for this before?
How long ago?
13. What treatment did you receive?
14. Results of previous treatment?
Comments
15. Were you referred to our office by anyone?
16. Is this condition interfering with
17. List any other major injuries you have had, other than those mentioned above:
18. Any other Musculoskeletal problems?
Neurological problems?
Additional information
I certify that the above information is accurate to the best of my knowledge.
Patient/Guardian Signature:
Date:

MonthDayYear
Date
Should be Empty:

CASE QUESTIONNAIRE