Pain Form - Existing Patients

1. Please indicate your usual level of pain during the past week:
2. Does pain, numbness, tingling or weakness extend into your leg (from the low back) &/or arm (from the neck)?
3. How would you rate your general health?
4. If you had to spend the rest of your life with your condition as it is right now, how would you feel about it?
5. How anxious (e.g. tense, uptight, irritable, fearful, difficulty in concentrating/relaxing) you have been feeling during the past week:
6. How much you have been able to control (i.e., reduce/help) your pain/complaint on your own during the past week:
7. Please indicate how depressed (e.g. Down-in-the-Dumps, Sad, Downhearted, In Low Spirits, Pessimistic, Feelings of Hopelessness) you have been feeling in the past week:
8. On a scale of 0 to 10, how certain are you that you will be doing normal activities or working in six months?
9. I can do light work for an hour?
10. I can sleep at night:
11. An increase in pain is an indication that I should stop what I am doing until the pain decreases:
12. Physical activity makes my pain worse?
13. I should not do my normal activities including work with my present pain:

Thank you for taking the time to fill out this form.


We look forward to hearing from you


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Arlington Chiropractic


9:00 am-7:00 pm


8:30 am-7:00 pm


9:00 am-7:00 pm


9:00 am-7:00 pm


8:00 am-5:00 pm


8:00 am-1:00 pm