Leg Pain Questionnaire

Lower Back Pain Questionnaire - 404-355-0743
Name: Please circle one: My back hurts: more on the right My leg hurts: more on the right Lower Back Pain Questionnaire Date: more on the left ... View Full Source

Pain Questionnaire - EvergreenHealth
Pain Questionnaire Referring 25% Neck or Back Pain, 75% Arm/Shoulder or Leg/ Buttock Pain Microsoft Word - Pre-procedure Questionnaire Author: gneubert Created Date: 10/3/2012 11:20:03 AM ... Document Retrieval

Back And Leg Pain Scale - WKHS
Using the pain scale above, please rate your current pain level. Back_____ Leg_____ Using the pain scale above, please rate your average pain. Back Using the pain scale above, please rate your pain at the best. Back_____ Leg_____ Title: Microsoft Word - Back and Leg Pain Scale.doc ... Document Viewer

Pain Questionnaire - OrthoBethesda Orthopedic Maryland
Pain Questionnaire Name of Patient_____ Date of Birth_____ Today’s Date_____Physician’s your pain is -- (Total = 100%) (R) Leg____% (L) Leg____% Back____% 4. If you have neck problems, what percent of ... Access Doc

Pain Questionnaire - EvergreenHealth
Pain Questionnaire Referring Physician: Primary Care Provider: 1. My current pain 100% Neck or Back Pain 100% Arm/Shoulder or Leg/Buttock Pain 50% Neck or Back Pain, 50% Arm/Shoulder or Leg/Buttock Pain 75% Neck or Back Pain, 25% ... Fetch Document

PATIENT QUESTIONNAIRE CM606−000 R09/11 Do Not Write Below This Line Yes No Pain caused by: No specific event Work injury Car accident Surgery Do you have pain in other locations? Yes No If yes, please specify: Leg Choose the number that describes your pain: ... Document Retrieval

PATIENT QUESTIONNAIRE FOR LOW BACK, BUTTOCK, AND LEG PAIN
Name _____ date_____ date of birth _____ patient questionnaire for low back, buttock, and leg pain ... Fetch Content

NAME DATE DATE OF BIRTH - Colospine.com
Patient questionnaire for low back, buttock, and leg pain . chief complaint (mark all that apply): low back __ _____ leg pain_____ buttock_____ other_____ (describe) list where do you have pain (mark on the pictures with symbols): ... Read More

Lower Limb Outcomes Questionnaire - AAOS
Lower Limb Outcomes Instrument: Page 3 of 4 Lower LimbQuestionnaire Today’s Date / / Thank you for completing this questionnaire! This questionnaire will help us to better understand your ... View Document

Work Capacity Test - Wikipedia, The Free Encyclopedia
Work Capacity Test. The Work Capacity Test (WCT), they must fill out a Health Screening Questionnaire (HSQ). This must be done prior to conditioning for, have a history of a heart condition or chest pain or loss of balance, ... Read Article

Oswestry Low Back Pain Scale - Whiplash Information
Oswestry Low Back Pain Scale Please rate the severity of your pain by circling a number below: No pain 0 1 2 3 4 5 6 7 8 9 10 Unbearable pain ... Access Doc

Lyme Disease Screening Quiz - About.com
Lyme Disease Screening Quiz. Is Lyme disease only found in Connecticut? How can you prevent Lyme disease? Do you have any of the symptoms associated with Lyme disease? ... Read Article

Lower Extremity Functional Scale - Sentara Healthcare
The Lower Extremity Functional Scale We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are ... Doc Retrieval

Low Back Pain Questionnaire - DISC Spine Institute
LOWER BACK PAIN Questionnaire For patients with lower back and leg pain: If you have pain in both your lower back and legs, which area is worse? Lower Back _____ Legs _____ Which leg hurts more? Right Left Equally painful How far down does ... Get Content Here

Patient Questionnaire - Pain And Rehabilitation Medicine
Introduction We would like to welcome you to Pain & Rehabilitation Medicine. Thank you for selecting our team. We are committed to provide you ... Doc Retrieval

Örebro Musculoskeletal Pain Questionnaire
Örebro Musculoskeletal Pain Questionnaire (Linton, S.J. & Boersma, K., 2003) Today’s Date: / / Claim No.: Name: Job Title: Work Status: leg. arm. other (state) _____ 4. How many days of work have you missed because of pain during the past 12 months? ... Fetch Here

Development And Validation Of A questionnaire To Measure The ...
Preliminary ‘exercise induced leg pain questionnaire for German-speaking people’ (EILP-G). Step III (pretesting): The preliminary EILP-G questionnaire was completed by a cohort of five patients with exercise-induced leg pain. ... Document Viewer

PART I - Kaiser Permanente
00324-001 (REV. 4-08) DISTRIBUTION: OUTPATIENT CLINIC CHART Page 1 of 12 MR#: Name: Date: MD: Regional Spinal Surgery Low Back/Leg Pain intake Questionnaire ... Read Document

Canvas Chiropractic Back Pain Index Mobile App - YouTube
The Chiropractic Back Pain Index questionnaire app gives information about how your patient's back condition affects their everyday life, from normal activities such as walking to more intensive situations like traveling. This app allows you to consistently capture information from ... View Video

Spine Pain Questionnaire - Twin Cities Orthopedics
Spine Pain Questionnaire Patient Name: _____ Date: _____ Referred By Back _____ % + Leg _____ % = 100% If you have pain in your legs, which is worse: Right _____ Left _____ Equal _____ ... Retrieve Here

STRONG HEART STUDY PHASE I DATA DICTIONARY ROSE QUESTIONNAIRE ...
Strong heart study phase i data dictionary rose questionnaire form position variable type length label response question no 4 idno char 6 shs id number numbers 26 rose13 char 1 leg pain walking uphill or hurry 1=yes, 2=no, 3=never hurries or walks ... Read Document

The Roland-Morris Low Back Pain And Disability Questionnaire ...
The Roland-Morris Low Back Pain and Disability Questionnaire Patient name: File # Date: Please read instructions: When your back hurts, you may find it difficult to do some of the things you normally do. Mark only the sentences that describe you today. I stay at home most of the time because of ... Read Content