Spine Health Assessment Please select the option that best describes you. Did you have a severe fall or accident related to this episode of discomfort? Yes No Click on the body part which is causing you the majority of your discomfort Left Right How long have you had discomfort in your ? Less than 3 months 3 months or more Any other body part feeling discomfort? (click below if related to your ) Left Right None Does your leg or buttock pain feel better when you do this? Yes No Indicate your pain level in your today No pain Worst possible pain 012345678910 Do you think your pain may become persistent? No Yes How much have you been bothered by feeling depressed in the past week? Not at all Somewhat Extremely How tense or anxious have you felt in the past week? Absolutely calm and relaxed Somewhat tense and anxious As tense and anxious as I've ever felt Based on all things you do to cope with your discomfort, on an average day, how much are you able to decrease it? Can decrease it completely Can decrease it partially Can't decrease it at all I have only walked short distances because of my discomfort Disagree Agree I have dressed more slowly than usual because of my discomfort Disagree Agree How well informed do you feel about your spine condition? Very Somewhat Not at all Have you ever in the past received any of the following treatments, related to your discomfort? Chiropractic Acupuncture Physical Therapy Injections Surgery Pain Medications None Which of the following apply to you now? (click as many as appropriate) Personal history of cancer Difficulty urinating OR controlling urine OR loss of bowel control Numbness where you wipe (anal or vaginal) Worsening weakness in arms or legs Fever > 101.5 degrees Unexplained weight loss > 10 pounds in last 3 months Previous longstanding steroid use Recent significant infection History of IV drug abuse None Is there any other relevant information we should be aware of as you are starting your program for your ? Chills or night sweats Chest pain at rest History of stroke or issues with vessels in neck Other None Which activity would you like to improve with this program? Daily LivingActivity Sports/Performance Activity Now please write the goal that you want to accomplish: 30 characters left Next Please select how well you can currently perform the goal of from 0 to 10: 012345678910 0Unable to perform activity 1 or 2Can perform activity but with significant pain and major restrictions/modifications 3 or 4Can perform activity but with moderate pain and moderate restrictions/modifications 5 or 6Can perform activity but with slight pain and with minor modifications 7 or 8Can perform activity virtually pain-free with minimal modifications 9 or 10Can perform activity without pain How many chiropractic visits have you had in the past? 1 2-3 4-5 6-8 9-11 12 or more Cancel Which of the following surgeries have you had in the past? Fusion Removal of Disc Other Cancel Ok How many pain medications have you been taking per day? < 1/day 1-2/day 3-5/day > 6/day Cancel
