Reassessment Form Page 2
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3Patient’s Name: ____________________________________________
Date of Birth:____________________ (DD/MM/YY)
Current Condition
If you have a specific condition, please complete the questions, otherwise go on to the next section of this form.
What is your major complaint? ______________________________________________________________
How long have you had this condition? _______________________________________________________
Did it begin:
Is the condition:
Is there pain:
Suddenly
Getting worse
Consistent
At night
Gradually
Getting better
Comes and goes
On coughing or sneezing
Describe if the pain travels:
_______________________________________________________________
Please mark your area(s) of concern using the symbols that you feel best describe what you are experiencing:
Numbness
- - - - - -
Burning
# # # # #
Stabbing
++++++
Pins &
: : : : : :
Needles
* * * *
Aching
Stiff /
/ / / / / / /
Tight
Place an “X” on the line to indicate the amount of pain/discomfort associated with your condition:
No Pain [0......1......2......3......4......5......6......7......8......9......10] Worst Pain Ever
What activities or positions cause aggravation: _________________________________________________
What activities or positions provide relief: ____________________________________________________
Please describe any past episodes: ___________________________________________________________
If there was an injury or event that lead up to this condition, please describe. _________________________
_______________________________________________________________________________________
If any health practitioner has previously treated you for this condition, please specify:
Location: _____________ When: ____________ Nature of Treatment ________________________
Can we follow up? (Please circle)
Yes
No
Has anyone else in your family had a similar complaint? __________________________________________
Other areas of concern: ____________________________________________________________________
Previous injuries: _____________________________________________________________________
Dr. Jennifer Heick
& Dr. Rebecca Blackburn
550 Parkside Drive, Unit A4, Waterloo ON N2L 5V4
519-746-3838 | |
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