Question

name: _______________

1. chief complaint: _____________________________________________________
2. onset: ______________________________________________________________
3. location: ____________________________________________________________
4. duration of complaint: ________________________________________________
5. intensity/ pain scale: _________________________________________________
6. character/type of the pain (burning, tingling, sharp, shooting, numb

________________________________________________________________________

1. referral areas: _______________________________________________________
2. aggravating factors: __________________________________________________
3. relieving factors: ____________________________________________________
4. medications: ________________________________________________________
5. previous treatment (dr., manual osteo, chiro, massage, naturopath)

________________________________________________________________________

1. affect on activities of daily living

Explanation:

This appears to be a medical history or patient complaint form. To fill it out, you would need the patient's information and details about their medical issue. For example:

1. Chief complaint:

Example: "Lower back pain and stiffness"

2. Onset:

Example: "3 days ago, after lifting a heavy box"

3. Location:

Example: "Lower back, specifically around the L4 - L5 region"

4. Duration of complaint:

Example: "3 days"

5. Intensity/ pain scale:

Example: "7 out of 10, where 10 is the worst pain imaginable"

6. Character/type of the pain (burning, tingling, sharp, shooting, numb)

Example: "Dull, aching pain with occasional sharp shooting pains"

7. Referral areas:

Example: "Pain radiates down the right leg to the back of the knee"

8. Aggravating factors:

Example: "Sitting for long periods, bending forward"

9. Relieving factors:

Example: "Lying down on a firm surface, gentle stretching"

10. Medications:

Example: "Ibuprofen 400mg as needed for pain"

11. Previous Treatment (Dr., Manual osteo, chiro, massage, naturopath)

Example: "Saw a chiropractor 2 days ago who performed spinal adjustments"

12. Affect on activities of daily living

Example: "Difficulty sitting at work, trouble bending to tie shoes, sleep is disrupted due to pain"

If you have a specific patient scenario or more details, you can provide them to get more tailored help with filling out the form.

Answer:

This appears to be a medical history or patient complaint form. To fill it out, you would need the patient's information and details about their medical issue. For example:

1. Chief complaint:

Example: "Lower back pain and stiffness"

2. Onset:

Example: "3 days ago, after lifting a heavy box"

3. Location:

Example: "Lower back, specifically around the L4 - L5 region"

4. Duration of complaint:

Example: "3 days"

5. Intensity/ pain scale:

Example: "7 out of 10, where 10 is the worst pain imaginable"

6. Character/type of the pain (burning, tingling, sharp, shooting, numb)

Example: "Dull, aching pain with occasional sharp shooting pains"

7. Referral areas:

Example: "Pain radiates down the right leg to the back of the knee"

8. Aggravating factors:

Example: "Sitting for long periods, bending forward"

9. Relieving factors:

Example: "Lying down on a firm surface, gentle stretching"

10. Medications:

Example: "Ibuprofen 400mg as needed for pain"

11. Previous Treatment (Dr., Manual osteo, chiro, massage, naturopath)

Example: "Saw a chiropractor 2 days ago who performed spinal adjustments"

12. Affect on activities of daily living

Example: "Difficulty sitting at work, trouble bending to tie shoes, sleep is disrupted due to pain"

If you have a specific patient scenario or more details, you can provide them to get more tailored help with filling out the form.