Physical Medicine Consultation & Evaluation to Utah Pain and Rehab - Integrated Healthcare and Pain Management in Ogden Utah

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Initial Physical Medicine Consultation & Evaluation

If 0% represents no pain, and 100% represents unbearable pain, please rate your pain by selecting when your pain is:

At its worst, At its best, and Most of the time…
At its worst:
At its best:
Most of the time:
What makes it better:
What makes it worse:
Social & Employment History
Marital Status:
Current Employment:

Part Time
Full Time
Job Duties / Activity Required:
Tobacco:

Yes
None
Alcohol:

Yes
None
What Supplements / Over-the-Counter Remedies have you tried:
What & Symptoms of Medical Allergies:
How Much/How Often/Why Used:
Medical Allergies
List any allergies and associated symptoms:
Medical History & ROS

For a current medical problem or a symptom you are currently experiencing. Please identify family members with these problems or those with similar symptoms.
Family Member & Relationship:
Problem(s):
No Family History or Current Family Medical Problems

None
Please check any of the following problems you currently or previously experienced.
Previous surgeries including dates:
Previous auto accidents, please include dates and details:
Previous Falls/ Injuries, please include dates and details
Security Code: *