Name:

Age:
Height:
Weight:

1. Do you have:
Back Pain
Right leg pain Right leg numbness Right leg weakness
Left leg pain Left leg numbness Left leg weakness

2. What pain is worse?
Back pain Right leg pain Left leg pain

3. On a scale of 0 to 10, with 0 = no pain and 10 = worst pain:
What is your back pain? 0 1 2 3 4 5 6 7 8 9 10
What is your leg pain? 0 1 2 3 4 5 6 7 8 9 10

4. Please show the location of your pain and other symptoms on the picture below (after printing)

Please mark your pain in the diagram on the right after printing this form: = Pain = Numbness/tingling

5. When did your back or leg pain start?

6. Since your pain began, are you currently:
Better Worse About the same

7. Was there an injury or event that caused the pain? Yes No
If yes, please explain:

8. Do you have a history of back/leg pain? Yes No
If yes, please explain:

9. Since your pain have you had any of the following treatments?

Medications? Yes No  If yes, what kind?

Physical Therapy? Yes No  If yes, did it help? Yes No
When did you last go to therapy?
Injections? Yes No  If yes, did it help? Yes No
Braces?  Yes No  If yes, did it help? Yes No

10. Are you working? Yes No  If yes, what do you do?

11. Have you had back surgery? Yes No  If yes, please expain.


12. Do you have any of the following:

Fever of Chills? Yes No
Recent weight loss? Yes No
Night pain? Yes No   If yes, is it worse than activity pain? Yes No
Bowel or bladder dysfunction? Yes No

13. Do you smoke? Yes No
If yes, how many packs per day?   How many years?

14 Do you consume alcohol? Yes No
What kind?   How often?