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Spurlock spine centre

Mid Back Complaints
Today’s Date: _____/_____/_____ Name:_________________________________________________ Circle the areas on your body where you feel the described sensations, and mark with the appropriate letter(s). For Office Use Only:
__________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________
Quality
1.) Reports
 Weakness left arm
EXPLAIN_________________________________________  Weakness right leg  Sexual dysfunction __________________________________________  Weakness both arms  Weakness both legs __________________________________________ EXPLAIN_________________________________________ __________________________________________ __________________________________________ 3.) Overall Status Describe how your pain has changed recently.  No change  Feels better  Feels worse  Requiring more medication 4.) Is this a similar or recurrent problem?  Deny previous episodes  Recurrent problem for ___________________  Similar to previous___________________ 5.) Please circle the number which best describes your pain level, or if the pain varies, list a range (0-No Pain and 10-Worst Pain): 0 1 2 3 4 5 6 7 8 9 10 or Range:________________________________________________________________________
Name:_____________________________________ Date:_______________________

SCC - Mid Back Rib Chest Complaints/revised 08/12vy
Duration
7.) How long have you had this current episode or symptoms? ________________________________________________________
How did it begin? _________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________
Timing
8.) What activities or positions RELIEVE or DECREASE your pain?
 Nothing
 Bending Neck Backward  Heating Pad  Bending Neck Forward  Cold Packs  Other, describe:________________________________________________________________________________________ 9.) What activities or positions INCREASE your pain?
 Nothing
 Bending Neck Backward  Extreme of Motion  Lifting  Bending Neck Forward  Cold Packs  Other_________________________________________________________________________________________________
Previous Treatment
10.) Which of these treatments have improved your condition?
 Chiropractic  TENS/e-stim  Exercise  Steroid Meds  Musc.Relaxers  Neurontin, Lyrica  Epidural Injection  Other_________________________________________________________________________________________________
11.) Which of these treatments did not improve your condition?
 Chiropractic  TENS/e-stim  Exercise  Steroid Meds  Musc.Relaxers  Neurontin, Lyrica  Epidural Injection  Other_________________________________________________________________________________________________ 12.) Which of these treatments are you currently receiving?  Chiropractic  TENS/e-stim  Exercise  Steroid Meds  Musc.Relaxers  Neurontin, Lyrica  Epidural Injection  Other_________________________________________________________________________________________________
13.) Who were you previously treated by?
 Neurosurgeon____________________________  Neurologist_______________________________  Orthopedic Surgeon_______________________  Chiropractor______________________________  Pain Clinic ________________________________________________  Other____________________________________ When was your most recent MRI, CT, or XRAY of problem area?___________________________________________________ Where was it performed?____________________________________________________________________________________
Office use only:
Which of these treatments have not been attempted or prescribed?
 Chiropractic  TENS/e-stim  Exercise  Steroid Meds  Musc.Relaxers  Neurontin, Lyrica  Epidural Injection  Other_________________________________________________________________________________________________ SCC - Mid Back Rib Chest Complaints/revised 08/12vy

Source: http://www.spurlockchiropracticcentre.com/Data/Content/New%20Patients/Forms/SCC/SCC-Complaint%20Mid%20Back.pdf

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