Below you will find several forms that will help us to better understand your symptoms, function, and monitor improvements. Scroll down and print those forms that pertain to your specific health condition.
SYMPTOM DESCRIPTION - Required
This form helps us to become more informed about the specific symptoms that you are experiencing. Please be specific as to the quality of your symptoms (burning, aching, etc.), but if the exact symptom isn't represented at the top of the form, please feel free to ad lib and make your own symbol to indicate to us what you are feeling. When filling our the pain scale(s), be aware that "0" represents no pain and "10" represents excruciating, unbearable symptoms.
BACK INDEX
This form is used to describe and quantify middle back and lower back symptoms, as well as how your symptoms affect your ability to perform daily activities.
NECK INDEX
This form is used to describe and quantify neck symptoms, as well as how your symptoms affect your ability to perform
daily activities.
HEADACHE INDEX
This form is used to describe and quantify your headache symptoms, as well as how your symptoms affect your ability to perform daily activities.
SHOULDER/ARM/HAND
This form is used to describe and quantify symptoms that affect your shoulder, arm, elbow, forearm, wrist and/or hand.
HIP/LEG/FOOT
This form is used to describe and quantify symptoms that affect your hip, thigh, knee, leg, ankle and/or foot.