Pain Profile Form Pain Profile Form First Name: Last Name: Sex: (Click One) MaleFemale DOB: Height It. It. Cument Weight: Jbs. Goal Weight Jbs. E-mail (username): Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: PLEASE ANSWER THE FOLLOWING: What is your area of greatest pain? What other areas of your body give you pain? Have you been given a diagnosis in the past? Yes If yes, what was it? No If yes,what was it? What made you want to do something about your pain today? Please check the box if you have or have had any of the below. CancerDiseaseKidney Metabolic DiseasePlatelet Dysfunction SyndromeCitical thrombocytopeniao cuteoporosHemodynamic instabilityConsistent use of NSAID within 48 hours of procedureSystemic use of corticostero within 2 weeksCorticostejection at loca tion of pain within 1 monthRecent fever or inessSleeping DisordersUkerAcid Reflux DiseaseNumbing/Tinging in Arms HandsNumbing/Tinging in Leg/feetPan in the legsPan in the feetDigestive ProblemsCarpal TunnelHemoglobin less than 10 gidDabetesArthritisBonent ProblemsHeart DiseaseImmune System DiseaseGastrointestinal DiseaseHypertension high blood pressureLung/Pulmonary DiseaseMiganesPancreasStrokeNeuromuscular DiseaseLow Back PainNeck PainTension/Headaches From OtherPlatelet count under 105/ Which of the above bothers you the most? How long have you had it? How often does it occur? What activities would you like to do if this was not a problem? What have you tried to relieve/get rid of this problem? MedicationsExerciseNothingPhysical Therapy NutritionOtherChiropractic CareStretching Patient Signature Date Provider Signature Date Δ
