Progressive Evaluations

Patient Follow-Up Questionnaire

Describe all your current symptoms (Neck, mid back, low back pain, headaches, knee pain…):
Since the beginning of treatment, has any specific activity increased your pain symptoms?
Do you have any new complaints?
How often do you experience your symptoms?

Indicate on the figure where you are experiencing symptoms using the key code below.

S = Sharp

D = Dull Ache

N = Numb

T = Tinging

B = Burning

W = Weakness

ST = Stiff

Mark Your Pain Point

Rate the level of pain from 1-10 (10 being the absolute worst pain):

How are your symptoms changing?

How do your symptoms affect your ability to perform daily activities? (circle appropriate number)

What changes have been made in your general feeling? (check those that apply)
What activity(ies) are easier to perform? (check those that apply)

How would you rate your percentage (%) of improvement for each area of complaint?

Are you performing any exercises, stretching, or sporting activities at this time?
Are you satisfied with the treatment you have received to date?

Recreational Activity (Sports, Hobbies,…): Effects of Current Condition on Performance

Activity Performance
Activity Performance
Condition's Effect on Job Performance:

Employment, ADL, and Recreation Information

Please review the activities listed below carefully and indicate in the boxes whether you are unable to perform, limited in performing the task due to pain, can perform but experience pain at the time or if the activity has no affect on your ability to perform the activity. This information is used to determine medical necessity according to several insurance companies.

Daily Activities: Effects of Current Condition on Performance

Bending
Change Posn-Sit-Stand
Climb Stairs
Driving
Exercise
Household Chores
Kneeling
Lifting
Reading/Deskwork
Self Care (Bathing, Dressing)
Sexual Activities
Sleep
Sitting (prolonged pds)
Standing (prolonged pds)
Walking
Yard Work

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

Lodes Chiropractic Center

Address

Shipley Building, 3411 Silverside Rd # 101,
Wilmington, DE 19810

Monday  

7:30 am - 5:30 pm

Tuesday  

1:30 pm - 5:00 pm

Wednesday  

7:30 am - 6:30 pm

Thursday  

2:00 pm - 5:30 pm

Friday  

7:30 am - 12:00 pm

Saturday  

Closed

Sunday  

Closed

CONTACT US

!
!
!

Please do not submit any Protected Health Information (PHI).