Patients'Global Impressionof Change(PGIC) scale.

Name: Date: DOB:

Chief Complaint:

Sfurcebeginningtreatmentat thisaxiniqh$ii/ipodd youdrscribeitre*hangetif any}irr

ACTIVTIT I.tuIITATIONS,SYMPTOMS,AhlOTI*lt[$ srd OVFK.{I"L QUALTTYOFLI}T,,
relatedto yourpainfirl ccnditisn'lftiekOI'IEbax).

{*r: c*s:lditi*nlrmsgmtl*'ffr$*]
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Nei cErange lli
i'"1
Alrntr*l.th* #nsn*,him l]' iffi]r {:tiiftmge
{rti*[tr f t
H
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!

r-T '1
A. lirntreh*tter, bertr:t: *rtrfice*bleuhnmge ,l I
LI
\

n t

Surtleaof^rffi huf th* *tr*,ng*hnrxm*[ maeif;mn]ir'trll diffbrfist{;fi

hryffier* iUt {
f

h'{*d*rateh,"fuatf*l',ltnd mslight l-ru{noticcshl* *furtnge il \

Eetter,ands drfirdt* irnprov*n$ntthaiha*m*dea rrol ard wffthwkils dilTerenee il 6

& pEat dwl bener.snda c*neiderabl*improve*er*thst hasma.de atl the diiferenre Il ?

In a similar way, pleasecircle the number below,that matchesyour degreeof changesince

beginningcare at this clinic:

Much No Much
Better Change Worse

0 1 2 3 4 5 6 7 8 9 10

Patient's signature: Date:

Reference:Hurst H, Bolton J. Assessingthe clinical significanceof changescoresrecordedon

subjectiveoutcomemeasures.J Manipulative Physiol Ther 2004;27:26-35.