Date Of Visit

Name

Date of Birth

Phone Number

Have you experienced any of the following?

Check all that apply.

• Back Pain

• Neck Pain

• Numbness or Tingling

• Joint Pain

• Muscle Stiffness

How would you describe the pain?

Check all that apply.

• Sharp

• Throbbing

• Burning

• Dull

• Radiating

When did the problem start?

What activities worsen the pain?

What activities relieve the pain?

Please list any existing medical conditions