Patient Examination and Questionnaire Sheet

Patient Examination and Questionnaire Sheet

Patient Name__________________________SS#_____________________Date________

Age________Height________Weight___________B/P_____________Pulse Rate_______

Appearance________________________________________________________________

Medications |Dosage | Effectiveness| Adverse Side-Effects

______________________mg 1234568910 groggy confusion bloating wt gain constipation

Severity Scale (1-10): 1-2= aching/stinging; 2-3=painful, 4-5=distracting painful,

6-7=very painful/stabbing, 8-9=incapacitating, 10=intolerable

Symptom | Severity | Frequency | Location / Type / Effects

Fatigue ___________hrly daily wkly month + tired drained exhausted incapacitated all

Headache___________hrly daily wkly month + eye temple back tension band migraine all

Confusion__________hrly daily wkly month + some mild troubling severe disorienting all

Body Pain ________ hrly daily wkly month + neck shoulder arm hand hip knee leg feet all

Insomnia___________nightly + wkly month + unrested groggy loss of comprehension all

Comprehension_______daily wkly month + ok-retain some-clouded little-quickly lost

Concentration_______hrly daily wkly month + ok-long poor-short very poor-brief bad-none

How much can the Patient do or has capacity for (using 1-10 scale)?

Lifting: Right Hand? 1-2 lbs 3-5 5-10 10-20 + easy effort painfully

Left Hand? 1-2 lbs 3-5 5-10 10-20 + easy effort painfully

Carrying: Right Hand? 1-2 lbs 3-5 5-10 10-20 + easy effort painfully

Left Hand? 1-2 lbs 3-5 5-10 10-20 + easy effort painfully

Strength: Right Hand? 1 2 3 4 5 6 7 8 9 10 easy effort painfully

Left Hand? 1 2 3 4 5 6 7 8 9 10 easy effort painfully

Use of hands for fine Manipulation? excellent good fair poor

Pushing? good weak fair poor Pulling? good weak fair poor

Sitting in a chair? 1-5 mins 5-10 10-15 15-20 20-30 30-45 60 +

Standing? 1-5 mins 5-10 10-15 15-20 20-30 30-45 60 +

Bending? 1-5 mins 5-10 10-15 15-20 20-30 30-45 60 +

Walking? 1-5 mins 5-10 10-15 15-20 20-30 30-45 60 +

Balancing without help? easily with effort great effort cannot

Patient Name__________________________SS#____________________Date________

Can the Patient: Use Feet to Push and Pull leg controls? yes painfully no

Kneel? yes painfully no

Squat? yes painfully no

Reach above? yes painfully no

Crawl? yes painfully no

Climb? yes painfully no

Stoop? yes painfully no

Can the Patient: Persistently sustain concentration? yes some poorly no

What is the Patient's ability to:

Listen and comprehend? excellent good poor very poor

Understand, remember and follow instructions and details? yes ok poorly no

Interact appropriately with others in a work setting? yes some poorly no

Interact appropriately with others in a social setting? yes some poorly no

Adhere to a regular work schedule? yes no

Objective signs of pain:

redness spinal/joint deformity joint noise x-ray muscle spasm

Pain is?

Mild - would constitute awareness, but causing no handicap in the performance of the

particular activity, would be considered as non-ratable permanent disability.

Slight - could be tolerated but would cause some handicap in the performance of the

activity precipitating pain.

Moderate - could be tolerated but would cause marked handicap in the activity

precipitating the pain.

Severe - would preclude the activity precipitating the pain.

Is the Patient restricted from work activities involving:

unprotected heights, moving machinery, work equipment, diesel or other exhaust, dust, fumes, gases, noise, use of hands and feet?

all yes no could not work at all

On the average, how often do you anticipate the impairments or treatments would

cause the Patient to be absent from work each month?

1 2 3 4 5 6 7-10 11-15 15+ could not work at all

Does the Patient have the capacity for regular work attendance? yes no

Patient Name___________________________SS#_____________________Date_________

Precipitating and aggravating factors:

movement in/activity heat cold light environmental conditions vibration

off schedule diet stress chemicals? all

other _________________________________________________________

Tender Point evaluation, number of tender points found:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18_______________

Does the Patient meet the American Rheumatological Criteria for Fibromyalgia (FMS)?

yes no ____________________________________________________________

Are depressive symptoms present? yes no

_______________________________________________________________________

Are symptoms of Anxiety present? yes no

_______________________________________________________________________

How long has the Patient had these symptoms?_____months____years _____new

Patient is not disabled and should return to work: yes no

_______________________________________________________________________

Patient remains disabled indefinitely because of the following symptoms: yes no

_______________________________________________________________________

Doctor’s Notes:

_______________________________________________________________________

Office Phone #_________________________________________________________

Office Address_________________________________________________________

Treating Physician_____________________________________________________

SSN or EIN_____________________________

Signature________________________________________ Date________________