Daily Assessment: 12/7
Patient Daily Assessment 2009
Please FULLY COMPLETE the following assessment so that we may better continue with your treatment plan.
*
1
. Your Full Name:
Your Full Name:
2
. If you are visiting for an Orthotic Refurbishment ONLY today, please check below and you do not need to complete the rest of the intake form.
Thank You
If you are visiting for an Orthotic Refurbishment ONLY today, please check below and you do not need to complete the rest of the intake form. Thank You
Gait Scan Visit
3
. Please tell us SPECIFICALLY your #1 area of concern/condition.
Please tell us SPECIFICALLY your #1 area of concern/condition.
4
. Today has your condition:
Today has your condition:
Improved
Same
Worse
5
. Mark the main areas of your pain/functional limitations:
Toes
Foot
Ankle
Leg
Knee
Hip/Back
Right
Mark the main areas of your pain/functional limitations: Right Toes
Foot
Ankle
Leg
Knee
Hip/Back
Left
Left Toes
Foot
Ankle
Leg
Knee
Hip/Back
Both
Both Toes
Foot
Ankle
Leg
Knee
Hip/Back
Other (please specify)
6
. Please rate your pain level today:
Please rate your pain level today:
1 (least pain)
2
3
4
5
6
7
8
9
10 (most pain)
7
. We believe that medical acupuncture is a valuable asset to your treatment plan. Will you be having acupuncture today?
We believe that medical acupuncture is a valuable asset to your treatment plan. Will you be having acupuncture today?
Yes
No
Not Sure
8
. Any other information you can tell us so that we may modify your treatment today?
Any other information you can tell us so that we may modify your treatment today?
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