MOTOR VEHICLE ACCIDENT PAIN CHART
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- Baldric Watts
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1 MOTOR VEHICLE ACCIDENT PAIN CHART Name Today s Date (D/M/Y) Area of Concern What is the WORST pain you have ever experienced? (other than the pain you are experiencing NOW!) What was the date of this painful experience? Please use the line scale provided below to rate this PAST pain! Circle the letter BELOW that best describes the limitation you are having NOW! a) Grade 0. No pain or discomfort Mild uneasiness may or may not be present Activities are not interfered with b) Grade 1. Minimal discomfort to mild pain Pain or discomfort is an annoyance Activities are normal but you have concern for certain motions or posture c) Grade 2. Slight pain to moderate pain Pain has a marked presence Pain reduces activities d) Grade 3. Moderate pain to severe pain Pain so imposing as to change lifestyle Pain dictates activities e) Grade 4. Severe pain to very severe pain Pain so overwhelming with little relief Only activity is in seeking relief f) Grade 5. Pain can vary from moderate to severe Pain has been long standing (6 months or more) Pain has only at times been interrupted by treatment Considerable time and effort is spent searching for relief from pain
2 Use the line scale provided below to answer the following three questions: 1. Rate the overall pain you are experiencing NOW! /10 2. The most common intensity of overall pain. /10 3. The level of pain at the onset. /10 DRAWING FOR AREA(S) OF CONDERN On the diagram below, indicate the areas of your body where you currently feel the described sensations. Use the appropriate symbol and include all affected areas. PAIN AREA(S): Ache //////////////////////// Burning bbbbbbbbbb Numbness Pins and Needles oooooooooo Stabbing ssssssssssssssss
3 NECK PAIN AND DISABILITY QUESTIONNAIRE (VERNON-MIOR) If you do not suffer from neck pain, please write n/a (not applicable). This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage in everyday life. Please answer EVERY section and mark in each section only ONE box which applies to you. We realize that you may consider that two of the statements in any one section relate to you but please just mark the box which most closely describes your problem RECENTLY. SECTION 1: PAIN INTENSITY I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment SECTION 2: PERSONAL CARE (Washing, Dressing, etc.) I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but manage most of my personal care I need help every day in most aspects of self care I do not get dressed, I wash with difficulty and stay in bed SECTION 3: LIFTING I can lift heavy weights without extra pain I can lift heavy weights but it causes extra pain Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned (e.g. on a table) I can manage light to moderate weights at the most I can only lift very light weights if they are conveniently positioned (e.g. on a table) I cannot lift or carry anything at all SECTION 6: CONCENTRATION I can concentrate fully when I want to with no difficulty I can concentrate fully when I want to with slight difficulty I have a fair degree of difficulty concentrating with I need to I have a lot of difficulty concentrating when I need to I have a great deal of difficulty concentrating when I need to I cannot concentrate at all SECTION 7: DRIVING I can drive my car without any neck pain I can drive my car as long as I want to with slight pain in my neck I can drive my car as long as I want with moderate pain in my neck I cannot drive my car as long as I want because of pain in my neck I can hardly drive at all because of severe pain in my neck I cannot drive at all SECTION 8: RECREATION I am able to engage in all my recreational activities with no neck pain I am able to engage in all my recreational activities with some pain in my neck I am able to engage in most, but not all, of my usual recreational activities because of pain in my neck I am able to engage in only a few of my usual recreational activities because of pain in my neck I can hardly do any recreational activities because of pain in my neck I cannot do any recreational activities at all SECTION 4: READING I can read as much as I want to with no pain in my neck I can read as much as I want to with slight pain in my neck I can read as much as I want with moderate pain in my neck I cannot read as much as I want because of moderate pain in my neck I can hardly read at all because of severe pain in my neck I cannot read at all SECTION 5: HEADACHES I have no headaches at all I have slight headaches which come infrequently I have moderate headaches which come infrequently I have moderate headaches which come frequently I have severe headaches which come frequently I have headaches almost all the time SECTION 9: SLEEPING I have no trouble sleeping My sleep is slightly disturbed (less than 1hr. sleepless) My sleep is mildly disturbed (1-2 hrs. sleepless) My sleep is moderately disturbed (2-3 hrs. sleepless) My sleep is greatly disturbed (3-5 hrs. sleepless) My sleep is completely disturbed (5-7 hrs. sleepless) SECTION 10: WORK I can do as much work as I want to I can only do my usual work but no more I can do most of my usual work but no more I cannot do my usual work I can hardly do any work at a I cannot do any work at all Neck Pain Severity Scale: Rate your USUAL level of NECK PAIN by circling one number on the following scale
4 INSTRUCTIONS: HEADACHE DISABILITY INDEX Please CHECK the correct response if applicable. Since being under care: 1. I have a headache: 1 per month More than 1 but less than 4 per month More than 1 per week 2. My headache is: Mild Moderate Severe INSTRUCTIONS: (Please read carefully) The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please check 1 response per line. Answer each question as it pertains to your headache only. Over the past 6 weeks: YES Sometimes NO Because of my headaches, I feel handicapped Because of my headaches, I feel restricted in my routine daily activities No one understands the effect my headaches have on my life I restrict my recreational activities (e.g. sports, hobbies) because of my headaches My headaches still make me angry I still feel that I am going to lose control because of my headaches Because of my headaches I am less likely to socialize My spouse/significant other, family or friends have no idea what I am going through because of my headaches My headaches are so bad that I feel that I am going to go insane My outlook on the world is affected by my headaches I am afraid to go outside when I feel that a headache is starting I feel desperate because of my headaches I am concerned that I am paying penalties at work or at home because of my headaches My headaches place stress on my relationships with family or friends I avoid being around people when I have a headache I believe my headaches are making it difficult for me to achieve my goals in life I am unable to think clearly because of my headaches I get tense (e.g. muscle tension) because of my headaches I do not enjoy social gatherings because of my headaches I feel irritable because of my headaches I avoid travelling because of my headaches My headaches make me feel confused My headaches make me feel frustrated I find it difficult to read because of my headaches I find it difficult to focus my attention away from my headaches and on other things
5 LOW BACK PAIN AND DISABILITY QUESTIONNAIRE (Revised Oswestry) If lower back pain does not apply, please write n/a (not applicable). This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer EVERY section and mark in each section only ONE box which applies to you. We realize that you may consider that two of the statements in any one section relate to you but please just mark the box which most closely describes your problem RECENTLY. SECTION 1: PAIN INTENSITY The pain comes and goes and is very mild The pain is mild and does not vary much The pain comes and goes and is moderate The pain is moderate and does not vary much The pain comes and goes and is very severe The pain is severe and does not vary much SECTION 2: PERSONAL CARE (Washing, Dressing, etc.) I can look after myself without extra pain I can look after myself normally but it causes extra pain Looking after myself increases the pain but I manage not to change my way of doing it Looking after myself increases the pain and I find it necessary to change my way of doing it I am unable to look after myself without some help because of the pain I unable to do any personal care without help because of the pain SECTION 3: LIFTING I can lift heavy weights without extra pain I can lift heavy weights but it causes extra pain Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned (e.g. on a table) I can manage light to moderate weights at the most I can only lift very light weights if they are conveniently positioned I cannot lift or carry anything at all SECTION 4: WALKING I have no pain when walking I have some pain when walking but it does not increase with distance I cannot walk more than 1km without increasing pain I cannot walk more than 1/2 km without increasing pain I cannot walk more than 1/4 km without increasing pain I cannot walk at all without increasing pain SECTION 5: SITTING I can sit in any chair as long as I like I can only sit in my favourite chair as long as I like Pain prevents me from sitting more than 1 hour Pain prevents me from sitting more than 1/2 hour Pain prevents me from sitting more than 10 minutes I avoid sitting because it increases pain straight way SECTION 6: STANDING I can stand as long as I want without pain I have some pain on standing but it doesn't increase with time I can't stand for longer that one hour without increasing pain I can't stand for longer than 1/2 hour without increasing pain I can't stand for longer than 10 minutes without pain I avoid standing because it increases that pain right away SECTION 7: TRAVELLING I get no pain whilst travelling I get some pain whilst travelling but none of my usual forms of travel make it any worse I get extra pain whilst travelling but it does not compel me to seek alternate forms of travel I get extra pain whilst travelling which compels me to seek alternate forms of travel Pain prevents all forms of travel except if laying down Pain prevents all forms of travel SECTION 8: SOCIAL LIFE My social life is normal and gives me no pain My social life is normal but increases the degree of pain Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing Pain has restricted my social life and I do not go out very often Pain has restricted my social life to my home I have hardly any social life because of pain SECTION 9: SLEEPING I get no pain in bed I get pain in bed but it does not prevent me from sleeping well My normal night's sleep is reduced by 25% or less because of pain My normal night's sleep is reduced by 50% or less because of pain My normal night's sleep is reduced by 75% or less because of pain Pain prevents me from sleeping at all SECTION 10: CHANGING DEGREE OF PAIN My pain is rapidly getting better My pain fluctuates but overall is definitely getting better My pain seems to be getting better but improvement is slow My pain is neither getting better nor worse My pain is gradually worsening My pain is rapidly worsening Low Back Pain Severity Scale: Rate your USUAL level of LOW BACK PAIN by circling one number on the following scale
6 LOW BACK PAIN DISABILITY QUESTIONNAIRE (Roland-Morris) When your back hurts, you may find it difficult to do some of the things that you normally do. Mark only the sentences that describe you CURRENTLY (within the last week). Because of my back pain, I stay at home most of the time I change position frequently to try and get my back comfortable Because of my back pain, I walk more slowly than usual Because of my back pain, I am not doing any jobs that I usually do around the house Because of my back pain, I use a handrail to get upstairs Because of my back pain, I lie down to rest more often Because of my back pain, I have to hold on to something to get out of an easy chair Because of my back pain, I try to get other people to do things for me Because of my back pain, I get dressed more slowly than usual Because of my back pain, I only stand up for short periods of time Because of my back pain, I try not to bend or kneel down Because of my back pain, I find it difficult to get out of a chair My back is painful almost all of the time Because of my back pain, I find it difficult to turn over in bed Because of my back pain, my appetite is not very good Because of my back pain, I have trouble putting on my socks (or stockings) Because of my back pain, I only walk short distances Because of my back pain, I don't sleep as well Because of my back pain, I get dressed with help from someone else Because of my back pain, I sit down for most of the day Because of my back pain, I avoid heavy jobs around the house Because of my back pain, I am more irritable and bad tempered with people than usual Because of my back pain, I go upstairs more slowly than usual Because of my back pain, I stay in bed most of the time Pain Severity Scale: Rate your level of low back pain TODAY by circling one number on the following scale
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PATIENT INTAKE FORM WELCOME and THANK YOU for seeking out care at our office. We are a very unique team specializing in research based spinal and postural rehabilitation that helps our patients recover
Child (0-17) New Patient Intake Form. Child s Health Summary
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NON-INJURY QUESTIONNAIRE
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CHIEF COMPLAINT: Answer the questions as completely as possible. If a question does not apply, leave it blank.
FOR OFFICE USE ONLY: Patient Number: Doctor: Insurance: Emp. Initials: CHIRO YEARLY REVAL: PATIENT INFORMATION: **Please give your Driver s License and insurance card to the front desk to copy for your
PATIENT HISTORY FORM
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Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
Welcome! Thank you for choosing our practice for your health needs. Your first visit to our center is an opportunity for us to learn all about you. If you have any questions or concerns, do not hesitate
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Name Date of Birth Today s Date
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did you feel sad or depressed? did you feel sad or depressed for most of the day, nearly every day?
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IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED
Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your
Parent Pain Questionnaire Understanding your child s pain
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We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
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INSOMNIA SEVERITY INDEX
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INITIAL INTAKE & EVALUATION FORM
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Sleep Health Center. You have been scheduled for an Insomnia Treatment Program consultation to further discuss your
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Mail: Omega Institute for Holistic Studies Attn: Registration Dept 150 Lake Drive Rhinebeck, NY Or scan and
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New Patient History Inventory
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Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
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