Print out, complete and bring this form to your doctor – this information will greatly assist in the diagnosis and treatment of your back pain.

When did your pain start? __________

What caused the pain?_______________

Have you had prior pain problems? (circle one)     YES       NO

Is your pain constant? (circle one)     YES       NO

Does your pain come and go? (circle one)     YES       NO

Which terms best describe your pain?

__ aching
__ throbbing
__ pounding
__ numbing
__ pins and needles
__ burning
__ stabbing
__ other (describe in your own words)
_________________________________________
_________________________________________

How bad is your pain?

__ mild
__ moderate
__ severe

Overall, is your pain generally:

__ improving
__ staying the same
__ worsening

Is the pain worse:

__ upon awakening
__ in the morning
__ mid-day
__ late in the day
__ evening
__ middle of the night
__ all the time

Is your pain relieved by:

__ ice or cold packs
__ heat (heating pad, hot shower, soak in the tub)
__ stretching
__ exercises
__ pressure
__ over-the-counter pain medications (aspirin or anti-inflammatory pills)
__ prescription pain pills
__ muscle relaxant pills
__ relaxation techniques
__ massage or manipulation
__ other
_________________________________________
_________________________________________

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