Returning Patient Paperwork

Re-Exam Packet

Patient Evaluation Chart and Questionnair

Name:

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Date:

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Primary Onset (select one):

Please indicate where your major symptoms are with the appropriate letters from the chart listed below.

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CP – Constant pain
P – Pain
S – Swelling
T – Tenderness
N – Numbness
Tg – Tingling
R – Redness
E – Effusion (puffiness or edema)
L - Limitation
W - Weakness

How long have you had these symptoms? (Itemize the different body areas if appropriate):

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Symptom List

Please list the concerns that brought you in today:

First Area of complaint:

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Pain level:

Mild Moderate Severe

Frequency:

Constant Intermittent

Symptoms:

Aches Stabs Burns Others

If others

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Rate your symptom level on a 0-10 scale. (0- no pain 5 moderate pain 10 worst pain possible):

Second Area of complaint:

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Pain level:

Mild Moderate Severe

Frequency:

Constant Intermittent

Symptoms:

Aches Stabs Burns Others

If others

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Rate your symptom level on a 0-10 scale. (0- no pain 5 moderate pain 10 worst pain possible):

Third Area of complaint:

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Pain level:

Mild Moderate Severe

Frequency:

Constant Intermittent

Symptoms:

Aches Stabs Burns Others

If others

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Rate your symptom level on a 0-10 scale. (0- no pain 5 moderate pain 10 worst pain possible):

Fourth Area of complaint:

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Pain level:

Mild Moderate Severe

Frequency:

Constant Intermittent

Symptoms:

Aches Stabs Burns Others

If others

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Rate your symptom level on a 0-10 scale. (0- no pain 5 moderate pain 10 worst pain possible):

Fifth Area of complaint:

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Pain level:

Mild Moderate Severe

Frequency:

Constant Intermittent

Symptoms:

Aches Stabs Burns Others

If others

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Activities of Daily Living Questionnaire

Work:

What type of work do you do?

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How many hours per day are you able to work now?

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Prior to Injury?

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Days per week now?

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How is your work affected or lost by your injury?

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Home/Family:

List the activities affected by your injury?

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Sleep:

How many hours per night do you sleep now?

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Prior to injury?

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Do you feel rested now?

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Prior to injury?

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What affects your sleep? (Examples- pain, not able to go to sleep, not able to wake up etc.)

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Social/Recreational:

Activities:

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Prior to injury?

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How are your current activities affected?

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Name:

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Date:

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Signature:

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Oswestry Neck Pain Disability Questionnaire

PLEASE READ: This questionnaire is designed to enable use to understand how much you NECK pain has affected your ability to manage your everyday activities. Please answer each section by selecting the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST SELECT THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.

Section 1 – Pain Intensity

A - The pain comes and goes and is very mild. B - The pain is mild and does not vary much. C - The pain comes and goes and is moderate. D - The pain is moderate and does not vary much. E - The pain comes and goes and is severe. F - The pain is severe and does not vary much.

Section 2 – Personal Care

A - I would not have to change my way of washing or dressing in order to avoid pain. B - I do not normally change my way of washing or dressing even though it causes some pain. C - Washing and dressing increases the pain, but I manage not to change my way of doing it. D - Washing and dressing increases the pain and I find it necessary to change my way of doing it. E - Because of the pain, I am unable to do some washing and dressing without help. F - Because of the pain, I am unable to do any washing or dressing without help.

Section 3 – Lifting

A - I can lift heavy weights without extra pain. B - I can lift heavy weights, but it causes extra pain. C - Pain prevents me from lifting heavy weights off the floor. D - Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently position. E - Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently position. F - I can only lift very light weighs, at the most.

Section 4 –Walking

A – Pain does not prevent me from walking any distance. B – Pain prevents me from walking more than one mile. C – Pain prevents me from walking more than ½ mile. D – Pain prevents me from walking more than ¼ mile. E – I can only walk while using a cane or on crutches. F – I am in bed most of the time and have to crawl to the toilet.

Section 5 – Sitting

A – I can sit in any chair as long as I like without pain. B – I can only sit in my favorite chair as long as I like. C – Pain prevents me from sitting more than one hour. D – Pain prevents me from sitting more than ½ hour. E – Pain prevents me from sitting more than 10 minutes. F – Pain prevents me from sitting at all.

Section 6 – Standing

A – I can stand as long as I want without pain. B – I have some pain while standing, but it does not increase with time. C – I cannot stand for longer than one hour without increasing pain. D – I cannot stand for longer than ½ hour without increasing pain. E – I cannot stand for longer than 10 minutes without increasing pain. F – I avoid standing, because it increases the pain straight away.

Section 7 – Sleeping

A – I get no pain in bed. B – I get pain in bed, but it does not prevent me from sleeping well. C – Because of pain, my normal night’s sleep is reduced by less than one-quarter. D – Because of pain, my normal night’s sleep is reduced by less than one-half. E – Because of pain, my normal night’s sleep is reduced by less than three-quarters. F – Pain prevents me from sleeping at all.

Section 8 – Social Life

A – My social life is normal and gives me no pain. B – My social life is normal, but increases the degree of my pain. C – Pain has no significant effect on my social life apart from limiting my more energetic activities, (example dancing, ect.) D – Pain has restricted my social life and I do not go out very often. E – Pain has restricted my social life to my home. F – I have hardly any social life because of the pain.

Section 9 – Traveling

A – I get not pain while traveling. B – I get some pain while traveling, but none of my usual forms of travel make it any worse. C – I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. D – I get extra pain while traveling which compels me to seek alternative forms of travel. E – Pain restricts all forms of travel. F – Pain prevents all forms of travel except that done lying down.

Section 10 – Changing Degree of Pain

A – My pain is rapidly getting better. B – My pain fluctuates, but overall is definitely getting better. C – My pain seems to be getting better, but improvement is slow at present. D – My pain is neither getting better nor worse. E – My pain is gradually worsening. F – My pain is rapidly worsening.

Additional Comments:

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Name:

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Date:

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Score:

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Oswestry Low Back Pain Disability Questionnaire

PLEASE READ: This questionnaire is designed to enable use to understand how much you LOWER BACK pain has affected your ability to manage your everyday activities. Please answer each section by selecting the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST SELECT THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.

Section 1 – Pain Intensity

A – The pain comes and goes and is very mild. B – The pain is mild and does not vary much. C – The pain comes and goes and is moderate. D – The pain is moderate and does not vary much. E – The pain comes and goes and is severe. F – The pain is severe and does not vary much.

Section 2 – Personal Care

A – I would not have to change my way of washing or dressing in order to avoid pain. B – I do not normally change my way of washing or dressing even though it causes some pain. C – Washing and dressing increases the pain, but I manage not to change my way of doing it. D – Washing and dressing increases the pain and I find it necessary to change my way of doing it. E – Because of the pain, I am unable to do some washing and dressing without help. F – Because of the pain, I am unable to do any washing or dressing without help.

Section 3 – Lifting

A – I can lift heavy weights without extra pain. B – I can lift heavy weights, but it causes extra pain. C – Pain prevents me from lifting heavy weights off the floor. D – Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently position (example- on a chair or table). E – Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently position. F – I can only lift very light weights at the most.

Section 4 –Walking

A – Pain does not prevent me from walking any distance. B – Pain prevents me from walking more than one mile. C – Pain prevents me from walking more than ½ mile. D – Pain prevents me from walking more than ¼ mile. E – I can only walk while using a cane or on crutches. F – I am in bed most of the time and have to crawl to the toilet

Section 5 – Sitting

A – I can sit in any chair as long as I like without pain. B – I can only sit in my favorite chair as long as I like. C – Pain prevents me from sitting more than one hour. D – Pain prevents me from sitting more than ½ hour. E – Pain prevents me from sitting more than 10 minutes. F – Pain prevents me from sitting at all.

Section 6 – Standing

A – I can stand as long as I want without pain. B – I have some pain while standing, but it does not increase with time. C – I cannot stand for longer than one hour without increasing pain. D – I cannot stand for longer than ½ hour without increasing pain. E – I cannot stand for longer than 10 minutes without increasing pain. F – I avoid standing, because it increases the pain straight away

Section 7 – Sleeping

A – I get no pain in bed. B – I get pain in bed, but it does not prevent me from sleeping well. C – Because of pain, my normal night’s sleep is reduced by less than one-quarter. D – Because of pain, my normal night’s sleep is reduced by less than one-half. E – Because of pain, my normal night’s sleep is reduced by less than three-quarters. F – Pain prevents me from sleeping at all.

Section 8 – Social Life

A – My social life is normal and gives me no pain. B – My social life is normal, but increases the degree of my pain. C – Pain has no significant effect on my social life apart from limiting my more energetic activities. D – Pain has restricted my social life and I do not go out very often. E – Pain has restricted my social life to my home. F – I have hardly any social life because of the pain.

Section 9 – Traveling

A – I get not pain while traveling. B – I get some pain while traveling, but none of my usual forms of travel make it any worse. C – I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. D – I get extra pain while traveling which compels me to seek alternative forms of travel. E – Pain restricts all forms of travel. F – Pain prevents all forms of travel except that done lying down.

Section 10 – Changing Degree of Pain

A – My pain is rapidly getting better. B – My pain fluctuates, but overall is definitely getting better. C – My pain seems to be getting better, but improvement is slow at present. D – My pain is neither getting better nor worse. E – My pain is gradually worsening. F – My pain is rapidly worsening.

Additional Comments:

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Name:

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Date:

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Score:

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Patient Care Progress Report

Name:

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Date:

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Our goal is to offer the very highest quality patient care possible. Would you help us by responding to these questions about your progress?

Changes often happen quickly during Initial Intensive Care as your body begins the natural healing process. Many patients neglect to tell us about them. Here’s a way you ca help us help you.

Care

What changes have you noticed since beginning care?

Positive changes:

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Negative changes:

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On a scale of 1 to 10, rate YOUR level of overall improvement.

On a scale of 1 to 10, rate the level of improvement of your spine so far.

Would you say your improvement is:

Progressing at the speed you expected. Taking longer than you expected Occurring much faster than you expected.

Do you think you could adequately describe the difference between initial intensive care and wellness care?

Yes No

Staff

How would you rate the concern shown by our staff?

How would you rate the training, qualifications, and competency of our staff?

Is there anyone who has been especially helpful?

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In what ways would you change the staff, office, or procedures we use to improve the quality of care?

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What do you like most about our office?

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We strive to fully inform our patients about their care and explain chiropractic and their health. How would you describe our educational efforts?

Excellent, I've learned a lot Helpful and interesting Still leaves some questions unanswered Could be significantly improved Waste of patients and staff time

Support

Children could avoid many health problems if they had Chiropractic care. Would you like the opportunity to bring your children?

Yes No

What kind of comments have you heard from your friends or family when you’ve told them about seeing a chiropractor?

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What has been your greatest difficulty when explaining chiropractic and what we do to others?

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Name of Authorized Person*

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Date Signed *

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Re-Exam Packet

Patient Evaluation Chart and Questionnair

Symptom List

Activities of Daily Living Questionnaire

Work:

Home/Family:

Sleep:

Social/Recreational:

Oswestry Neck Pain Disability Questionnaire

Oswestry Low Back Pain Disability Questionnaire

Patient Care Progress Report

Care

Staff

Support

Appointments

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