PAIN ASSESSMENT TOOL

Your pain

Describe pain

Your Symptoms

Past Treatment

Your Results

Please select your areas of pain

Arms Buttocks Legs Lower Back Middle Back Neck Shoulders

Where is the pain strongest?

Arms Buttocks Legs Lower Back Middle Back Neck Shoulders

Have you been diagnosed with a specific condition?

Yes, I have been diagnosed by a physician No, I have not been diagnosed by a physician

How would your describe your pain or symptoms?

None Sharp Burning Cramping Numbness & Tingling Radiating (throbbing) Shocking (quick jolts of pain

Are you always in pain?

Yes, I am in constant pain that worsens depending on what activity I am doing. No, it comes and goes depending on what activity I'm doing or what position I'm in.

When is your pain at its worst? Choose all that apply.

In the morning after waking up While standing or walking While bending backwards While sitting While lying down While performing strenuous activity

When does your pain feel better?

In the morning after waking up While standing or walking While bending backwards While sitting While lying down While performing strenuous activity

What caused your pain originally?

Not sure Lifting something heavy Vehicle crash Slip or fall Traumatic injury Leaning forward Other

Have you undergone any of the following?

CT Scan MRI Myelogram Discogram X-Ray Nerve Conduction Study Other None

First Name

Last Name

Phone

Comments

CONTACT

(210) 802-4662

Info@TexasSpineCare.com

3619 Paesanos Pkwy, Suite 302
San Antonio, TX 78231

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