Numbness: o o o o o. Grade your overall pain. Pain Rating Scale Mosby. Worst Possible Pain. No Pain HURTS LITTLE MORE HURTS EVEN MORE

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Patient Name: Original Referring Physician: Current PCP: PAIN DIAGRAM Is your condition the result of a: Work injury? YES NO Auto accident? YES NO Date of Injury: / / Please mark the areas of discomfort on the diagram below using the appropriate symbols below: Pain or burning: x x x x x Numbness: o o o o o Right Left R Pins and Needles: = = = = = Left L Right L R Grade your overall pain Pain Rating Scale Mosby No Pain 0 1 None NO HURT 2 3 4 Mild LITTLE BIT 5 6 7 Moderate LITTLE MORE EVEN MORE 8 9 Worst Possible Pain 10 Severe WHOLE LOT WORST Please place an X on the above hash mark that most accurately describes your overall degree of pain now. Please indicate in table below the percentage of pain you currently feel in your neck, arm, back and legs. Example (0%, 25%, 75%, 100%) For patients with neck and arm pain CF-026-NPI (2/15) Page 1 of 5 For patients with back and leg pain Neck Pain % Back Pain % Arm Pain % Leg Pain % Total Pain 100% Total Pain 100%

HISTORY: (Check all that apply) Chief Complaint: Back pain Leg: Pain Numbness Weakness Other Body Part (specify) Neck pain Arm: Pain Numbness Weakness Balance Deficit Gait Instability When did your present pain begin? How did your pain start? Date of Injury? OR: Less than 6 months More than 6 months Greater than 1 year My pain is: Worsening Improving Unchanged since it started For patients with NECK or ARM pain, numbness or weakness: For patients with BACK or LEG pain, numbness or weakness: Neck Pain R L Arm Pain R L Back Pain R L Leg Pain R L Numbness R L Weakness R L Numbness R L Weakness R L Do you have difficulty picking up small objects like coins or buttoning buttons? YES NO Do you have problems with balance or frequent tripping? YES NO Worst position for pain is: Sitting Standing Walking How many minutes can you stand/walk before you need to rest? 0-10 15-30 30-60 60+ Lying down: Eases the pain Does not ease the pain Sometimes eases the pain Bending forward: Increases the pain Decreases the pain Does not affect the pain There is: No loss of bowel or bladder control (incontinence) Loss of bowel and bladder control since: Other activities/positions that increase pain: Other activities/positions that reduce pain: I have: Not missed any work because of this problem How much work have you missed: Treatment has included: (Check all that apply) NO medication, physical therapy, chiropractic manipulations, injections, or bracing Anti-inflammatory medication Muscle relaxants Narcotic pain medication Physical Therapy Chiropractic manipulation Traction Acupuncture In-office injections without X-ray Epidural steroid injections Facet injections Sacroiliac (SI) Injections Braces Other: Previous doctors seen for this problem: Doctor Specialty City Doctor Specialty City Treatment CF-026-NPI (2/15) Page 2 of 5

PREVIOUS IMAGING STUDIES: (Check all that apply) X-Rays CT Scan MRI Myelogram EMG Bone Scan Results DEXA (bone density): PAST MEDICAL HISTORY: (Check all that apply) AIDS/HIV Blood clot in leg/lung Hepatitis Migraines Stomach Ulcers Alcoholism Bone fracture High blood pressure Osteoarthritis Thyroid disease Anemia Cancer Kidney failure Osteoporosis Tuberculosis Anesthesia problems Diabetes Kidney stones Rheumatoid arthritis Wound history Ankylosing spondylitis Glaucoma Liver disease Seizures Asthma GOUT Lung disease Serious injury (explain) Bleeding disorders Heart attack Mental illness Stroke Other: PAST SURGICAL HISTORY: (Check all that apply) Abdominal Heart Stent Pacemaker Appendectomy Hysterectomy Tonsillectomy Back Joint Replacement Vascular Cholecystectomy(Gallbladder) Mastectomy Other: Heart Neck MEDICATIONS List all PAIN medications and dosages taken for your current problem: Please list all current medications or provide list: ALLERGIES Please list any known allergies to food or medication and their reactions: FAMILY HISTORY: (Check all that apply) Stroke Alcoholism Kidney trouble or stones Seizures Bleeding disorders Arthritis Heart trouble Cancer Diabetes Anesthesia Anesthia problems Gout Mental illness High blood pressure Spine problems Other: SOCIAL HISTORY: (Check all that apply) Work Status: Homemaker Retired Disabled On leave Unemployed Employed Occupation: Marital Status: Married Single Divorced Widowed I live: Alone With: Do you smoke? Yes No packs/day for years Quit How long ago? Drink alcohol? Daily 1-2 x/week 1-2 x/month Never Alcoholic Recovering alcoholic Illicit drug use: Never Currently In the past CF-026-NPI (2/15) Page 3 of 5

Patient Name: Review of Systems Are you currently or have had problems with: * Please explain and describe all YES answers below Hematological / Bleeding problems Reproductive / Sexual problems Unexplained weight loss: Skin: Ear, Nose, Throat: Stomach / Digestion: Bladder / Bowel problems: Musculoskeletal: Neurological: Psychiatric problems: Fever / Chills: Night sweats: Night pain / Pain at rest: CF-026-NPI (2/15) Page 4 of 5

Office use only: Vitals: Age: Ht: Wt: B/P: Pulse: Temp: BMI: General: Gait: Assistive Devices: Cane Walker Rollator Spinal ROM: Cervical: Lumbar: Strength: UE: D B T WE WF FF LE: HF Q AT GS EHL Sensory: Normal Abnormal UE: C5 C6 C7 C8 T1 Non-derm LE: L1 L2 L3 L4 L5 S1 Non-derm Reflexes: UE: 1+ 2+ BRISK ABSENT LE: 1+ 2+ BRISK ABSENT Pathological: Clonus Babinski s Hoffman s SLR Vascular: Popliteal DP Post Tib CF-026-NPI (2/15) Page 5 of 5

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