Initial Evaluation

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Pain Intensity

Select the number correspoinding to your pain intensity, with "0" meaning "No Pain" and "10" meaning the most severe pain imagineable

Relieving and Aggravating Factors

How do the following affect your pain? Check One for each item:

Pain Treatments

Please check all of the treatments you have tried for your pain and then complete the appropriate column at the right to the best of your ability.

Functional Limitations

ALLERGIES

REVIEW OF SYSTEMS