When did the problem first occur?

How did the problem occur?

Was an incident/accident involved?

Describe what you are currently experiencing (ex. location of pain or type of symptom):

Has the condition been getting better or worse?

Is there a particular time of day these symptoms occur?

What makes the condition better (ex. Rest, lying down, movement etc)?

What makes the condition worse (ex. Movement, sitting, stress etc.)?

What aspects of your life have been affected (ex. Home, recreation, relationships, job etc.)?

Have you experienced similar conditions in the past?

If yes, describe:

Describe your daily physical requirements:

How would you rate your level of Stress?

If yes, by whom:

Are you currently being treated for any other conditions?

Please list all previous accidents or traumas:

Please list any past surgeries: