Date (MM/DD/YY)

First

Last


What results do you expect from your care?

Relief from pain symptoms
Return to your job
Return to leisure activities
Improved Sleep


Phone

Doctor you will see


 



 


The following are activities you might do in a typical day. Does your back or neck pain limit you in these activities? If so, how much?

Lifting or carrying groceries
limited a lot limited a little Not limited at all
Climbing several flights of stairs
limited a lot limited a little Not limited at all
Standing for 30 minutes
limited a lot limited a little Not limited at all

 





 

 

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