Please describe the health problem for which you came to our office:________________

_______________________________________________________________________

Describe your job postures (sitting, standing bending): ___________________________

How long have you had this episode of symptoms? ______________________________

Have you had the same condition in the past? Yes  No  How many times? ____________

When was the last time that you felt the same or similar symptoms? _________________

Symptoms began:         Suddenly          Gradually          Unknown

What makes your symptoms worse? __________________________________________

What makes your symptoms better? __________________________________________

Describe the character of your symptoms (burning, tingling, aching, tired, numb, sharp, dull, stabbing, shooting, radiating, etc.): _______________________________________

Rate your degree of pain from 1 to 10 (1 being the least and 10 the worst pain imaginable):  1    2          3          4          5            6          7          8          9          10

How often do you notice your symptoms?______________________________________

Are you pregnant ? (Females only)______________________________

Please mark the area(s) of your injury or discomfort on the diagrams.

I certify that I have read and understand the above Case History questions. The Case History questions have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my health.

Signature of Patient (or parent if a minor)                                                                        Date