Patient Health Questionnaire Chiropractic, Massage, Trigger Point Therapy, Salt Cave and more!Let us help you achieve your health goals! BOOK AN APPOINTMENT Leave this field blank Patient Health Questionnaire Dr. Janine D. Kelly (optional) 1762 Newbridge RoadBellmore, NY 11710 Patient Name Date 1. When did your symptoms start? Describe your symptoms and how they began: Indicate where you have pain or other symptoms (optional) 2. How often da you experience your symptoms? Choose Conctantly (76-100% of the day) Frequenty (51-75% of the day) Occasionally (26-50% of the day) lntermittently (0-25% of the day) 3. What describes the nature of your symptoms? Choose Sharp Shooting Dull ache Burning Numb Tingling 4. How are your symptoms changing? Choose Getting Better Not Changing Getting Worse 5. How bad are your symptoms at their? Please choose a number between 1 and 10. Choose 1 2 3 4 5 6 7 8 9 10 6. How do your symptoms affect your ability to perform daily activities? Choose No Complaints Mild, forgotton with activity Moderate, interferes with activity Limiting, prevents full activity Intense, preoccupied with seeking relief Sever, no activity possible 7. What activities make your symptoms worse? 8. What activities make your symptoms better? 9. Who have you seen for your symptoms? Choose No One Medical Doctor Other Chiropractor Physical Therapist Other a. When and what treatment? b. What tests have you had for your symptoms and when were they performed? Choose Xrays CTScan MRI Other Date 10. Have you had similar symptoms in the past? Yes No a. lf you have received treatment in the past for the same, or similar symptoms who did you see? Choose This Office Other Chiropractor Medical Doctor Physical Therapist Other 11. What is your occupation? Choose Professional/Executive White Collar/Secretarial Tradesperson Laborer Homemaker FT Student Retired Other a. what is your current work status? Choose Full-time Part-time Self-employed Unemployed Off work Other 12. What do you hope to get from your visit/treatment (select all that apply) Reduce symptoms Explanation of condition/treatment Resume/increase activity Leam how to take care of this on my own How to prevent this from occurring again Date Patient Signature Start Drawing Clear Done Start Over Send
