Sample Outcome Assessment/progress- Patient Questionnaire Template printable pdf download

NAME/ADDRESS of CLINIC/PROVIDER

OUTCOME ASSESSMENT/PROGRESS- PATIENT QUESTIONNAIRE

Name of Patient______________________________________Date _____________________

Patient DOB _________________________________

EXTREME

SYMPTOMS

Please place an “X” on the line above to indicate your level of problem.

What was the chief symptom or reason you visited the office? (low back pain, neck

pain, etc

.) __________________________________________________________

2. How do you classify your improvement so far since beginning your care?

Excellent ____________Good __________Fair ___________Poor _____________

3. On a scale of 1 to 10 with 10 being the best, how would you rate your improvement?_____

4. What symptoms have improved? _______________________________________

___________________________________________________________________

5. What symptoms do you still have? ______________________________________

___________________________________________________________________

6. What changes have been made in your general feelings? Are you: (check those indicated)

Stronger _____________ More Relaxed __________More Alert ____________

Less Nervous__________ Sleep Better ___________Appetite Improved ______

7. Do you find it easier: (check those indicated)

Walking _______

Riding ______

Working _____

Bending____

Standing_______

Sitting _______

Lifting _______

Same _____

8. Is there any other condition you have that we have not discussed that you would like to

discuss at this time?______If yes, please explain __________________________________

_________________________________________________________________________

9. Is there any confusion or question about any phase of your progress? ________________

_________________________________________________________________________

10. Do you intend to continue care to avoid problems in the future (check one)

Yes______ No______Will follow my doctor’s recommendations _____________

11. Have you had an opportunity to refer anyone to the Doctor? (check one)

Yes_____ No____ Intend to do so ___________________________________

12. Your honest evaluation of the Doctor’s office is always appreciated. Please comment on

any areas where the Doctor or Office may improve. _______________________

___________________________________________________________________

Reviewed by ______________________________________

Printed Name of Provider_____________________________

Outcome Assessment

Patient/Guardian Signature _________________________________

Sample Outcome Assessment/progress- Patient Questionnaire Template

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