Follow-up Spine Assessment Visit
| Date: | Date of Injury: | ||
| Name: | DOB: | ||
| Company: | Occupation/Job: |
Describe your current symptoms:
| Since your last visit how are you? | Better | Same | Worse |
| Rate your pain level (0=no pain, 10=worst pain) | 0 | 1 | 2345678910 |
| Rate your current level of activity (0=inactive, 10=regular activities) | 0 | 1 | 2345678910 |
| Are you working: | Light duty | Regular duty | Not working |
| What makes your pain worse? | |||
| Bending | Rising from sitting | Walking | Lying down, Coughing, Sneezing, Other |
| What makes your pain better? | |||
| Heat | Ice | Standing | Lying down, Not Working, Walking, Other |
| Do you have any difficulty sleeping because of your back pain? | No | Yes | |
| Have you had any change in your bowel habits since your injury? | No | Yes | |
| Have you had any changes in urination (e.g. difficulty starting, stopping or controlling)? | No | Yes | |
| Do you have any weakness in your legs / arms? | No | Yes | |
| What medications are you taking for this problem? | |||
| Have you had problems with your medication? | No | Yes | |
| Are you going to physical therapy or chiropractor? | No | Yes | |
| Are you performing home exercises? | Daily | Every other day | Occasionally No |
| Comments: |
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Using the symbols below, please mark the areas on the diagram where you feel
sensations. Please be sure to indicate all areas affected by the sensations.
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