QUESTIONNAIRE

· Date of Injury:_______________ How did your injury occur?

· List all previous surgeries/tests/treatments/therapy you have had.

· What medications are you presently taking and for what reason?

· Please list any previous accidents/injuries/illnesses you have had.

· Do you have a history of:

YES NO YES NO YES NO

___ ___ alcohol/drug use ___ ___ high blood pressure ___ ___ resp. problems

___ ___ allergies ___ ___ head injury ___ ___ seizures

___ ___ arthritis ___ ___ heart disease ___ ___ shortness of breath

___ ___ cancer ___ ___ mental illness ___ ___ smoking

___ ___ diabetes ___ ___ osteoporsis ___ ___ other:____________

___ ___ dizziness ___ ___ pace maker

· If applicable, is there a chance you could be pregnant? ___Yes ___No

· Do you have difficulty with any of the following (please check)?

___ dressing ___ light cleaning ___ yard work ___ driving

___ eating ___ heavy cleaning ___ automobile care ___ public transportation

___ grooming ___ vacuuming ___ child care ___ leisure

___ meal preparation ___ laundry ___ grocery shopping ___ sports

___ intercourse ___ other:_______________________________________________________

· What is your main physical complaint?

· What, if anything, increases your pain?

· What, if anything, relieves your pain?