Please Complete and Print these forms, ready for your visit. (Time Saver)

Please place an X in the exact location of your pain.

Circle all that apply!


Does your condition seem to be: IMPROVING, STATIC, \VORSE

Aggravating factors:   SITTING,   STANDING,   BENDING,   LIFTING,   WALKING, REACHING,   DRIVING,   EXERCISE

Worse in:   MORNING,   NIGHT,   OR BOTH

Does your condition affect:   WORK,   SLEEPING,   DAILY ACTIVITIES

Relieving factors:   HEAT,   ICE,   IBUPROFEN/ADVIL,   TYLENOL

Have you been seen by your local medical doctor for any related problems in the past year? If so please indicate when and for what exactly:


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