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    Symptom Survey

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    localon
    This document is a symptom survey from Potrero Chiropractors, a wellness center located in San Francisco. It collects information from a patient about areas of pain, pain levels, and amount of time spent in pain. The patient is asked to shade areas where they feel pain and label them with symbols to indicate type of pain such as burning, numbness, or spasms. They then rate their pain levels from 1 to 10 and indicate how often they experience pain in each body part, ranging from occasional to constant. The patient signs the form to provide this information.

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    Symptom Survey

    Uploaded by

    localon
    10 views1 page
    This document is a symptom survey from Potrero Chiropractors, a wellness center located in San Francisco. It collects information from a patient about areas of pain, pain levels, and amount of time spent in pain. The patient is asked to shade areas where they feel pain and label them with symbols to indicate type of pain such as burning, numbness, or spasms. They then rate their pain levels from 1 to 10 and indicate how often they experience pain in each body part, ranging from occasional to constant. The patient signs the form to provide this information.

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    SymptomSurvey

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    This document is a symptom survey from Potrero Chiropractors, a wellness center located in San Francisco. It collects information from a patient about areas of pain, pain levels, and amount of time spent in pain. The patient is asked to shade areas where they feel pain and label them with symbols to indicate type of pain such as burning, numbness, or spasms. They then rate their pain levels from 1 to 10 and indicate how often they experience pain in each body part, ranging from occasional to constant. The patient signs the form to provide this information.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    10 views1 page

    Symptom Survey

    Uploaded by

    localon
    This document is a symptom survey from Potrero Chiropractors, a wellness center located in San Francisco. It collects information from a patient about areas of pain, pain levels, and amount of time spent in pain. The patient is asked to shade areas where they feel pain and label them with symbols to indicate type of pain such as burning, numbness, or spasms. They then rate their pain levels from 1 to 10 and indicate how often they experience pain in each body part, ranging from occasional to constant. The patient signs the form to provide this information.

    Copyright:

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    of 1

    Frank Gilson, D.C.

    Office (415) 431-7600 Fax (415) 431-7608

    290 Division St. Suite 400 San Francisco, CA 94103

    Potrero Chiropractors

    A Wellness Center

    SYMPTOM SURVEY
    Patients Name

    Todays Date
    TELL US WHERE YOU HURT Shade the Area of Pain. Label with Appropriate Symbol

    P = Pain (Dolor) W = Weakness (Debilidad) N = Numbness (Entumeciminto) B = Burning (Ardor/Caliente) S = Spasm (Espasmo de Musculo) ST = Stiffness (Tiesura) T = Tingling (Estremecimiento)

    Area of Pain (check mark each area of pain) Mild Head Neck Shoulder(s) Arm(s) Upper Back Middle Back Lower Back Hip(s) Leg(s) Other List Any Other Current Symptoms: Lt. Lt. Rt. Rt. Lt. Lt. Rt. Rt. 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2

    Pain Scale (circle numbers) Moderate 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 Severe 8 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 10 10 10 10 10 10 10 10 10 Occasional 0 to 25% O O O O O O O O O

    Amount of Time You Are in Pain (circle one for each body part) Intermittent Frequent 25 to 50% 50 to 75% I I I I I I I I I F F F F F F F F F

    Constant 75 to 100% C C C C C C C C C

    Signature of Patient or Guardian

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