Pain Assessment Information Form

Please complete the form, print it out, and bring to your appointment.

Patient Name:	Date:
Right Handed Left Handed Ambidextrous
Who referred you to Dr. Zahl	Self friend another Doctor Other:
Are you off from work because of your current problem?	YES NO
If yes, what date have you been out of work since?
Related to a:	Motor Vehicle Injury Work Related Injury Other for which you filed a claim? Date:
Brief history of your current symptoms
Describe any relevant symptoms of this episode
On a scale of 1 to 10, please rate your pain (1 is very little pain and 10 is the worst pain imaginable)
Now At worst At best Doctor Average
Date of last episode:	How many episodes in the last year:

Are your symptoms:	Improving Unchanging Worsening
Numbness? Yes No :	Pins and Needles? Yes No
Symptoms at onset affected which area(s)?
Back Leg Neck Arms Hands Other:
Constant symptoms affect which area(s)?
Back Leg Neck Arms Hands Other:
Intermittent symptoms effect what area?
Back Leg Neck Arms Hands Other:
Are your symptoms worse during:
Bending Sitting Rising Walking Lying down AM PM As the day progresses
Do your symptoms worsen when:	Coughing Sneezing Straining
Are your symptoms better during:
Bending Sitting Rising Walking Lying down AM PM As the day progresses
Are you having any bowel problems?
YES NO Incontinence Constipation Other:
Do you have any bladder problems?
YES NO Incontinence Prostate Other:
Do you have any problems with sexual intercourse?
YES NO NOT APPLICABLE
Do you have problems walking?	YES NO
Do you have disturbed sleep?	YES NO
Sleep Position:
Face up Face down Right side Left side
Sleep surface:
Firm Soft Waterbed Other:
Are you depressed from the pain?	YES NO SOMETIMES
Have you had thoughts about, or ever attempted suicide?	YES NO
Do you experience headaches or facial pain?	All the time Sometimes Rarely
Would you rate your headaches as:	Mild Medium Severe
Migraines? YES NO	Sinus type pain? YES NO
Ringing in the ears? YES NO	Jaw or Pain in Teeth? YES NO
Pain in or Near Eyes? YES NO	Pain in back of head? YES NO
For this pain condition have you had any of the following?:

Physical therapy?	YES NO	Surgery?	YES NO
TENS?	YES NO	Psychotherapy?	YES NO
Massage Therapy?	YES NO	Biofeedback?	YES NO
Trigger Point injections?	YES NO	Taken narcotics?	YES NO
Acupuncture?	YES NO	Herbal or Aromatherapy?	YES NO
		Magnets?	YES NO
Pain management / Epidural injections?		YES NO
If yes, Doctor's name:
Town:		Phone:
Chiropractic Treatments?		YES NO
If yes, list Chiropractor:
Town:		Phone:
X-Rays / Cat scans / MRI's (dates):