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)

MorningIncrease during the dayAfternoonSame all dayNightDecrease during the day
3. Symptom (a.) is:

SharpDullBurningAchingThrobbingNumbnessTinglingPins & Needles
4. Symptom (b.) is:

SharpDullBurningAchingThrobbingNumbnessTinglingPins & Needles
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?

ImprovedGotten WorseStayed the same since it began
10. Select the things that make your problems worse:

BendingLyingWalkingStandingSittingMovementTwistingLiftingSleeping
11. Is there anything you can do to relieve the problems?

YesNo
If yes, describe:
If No, what have you tried that has not helped?
12. Have you been treated for this before?

YesNo
How long ago?
13. What treatment did you receive?
14. Results of previous treatment?

GoodPoor
Comments
15. Were you referred to our office by anyone?
16. Is this condition interfering with

WorkSleepDaily RoutineRecreation
17. List any other major injuries you have had, other than those mentioned above:
18. Any other Musculoskeletal problems?

YesNo
Neurological problems?

YesNo
Additional information
I certify that the above information is accurate to the best of my knowledge.
Patient/Guardian Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

CASE QUESTIONNAIRE