There is access to interpreter services for non-or-limited English proficient (LEP) members:
Yes, I will need interpreter assistants.No, I do not need interpreter assistants.
What is the history of the injury (reason, time of occurrence, is it getting better or worse)?
What surgeries have you had (if any), and when?
What areas of your body are in pain?
What is the level of pain out of 10? 0 = No pain. 10 = The worst pain possible.
Select any/all descriptions of the pain that apply.
SharpDeepBurningStabbingConstantIntermittentVariesWorse in AMWorse in PM
Does the pain disturb your sleep?
Other medical conditions:
Imaging done/results (x-ray, MRI):
Does the pain limit your activities at home? Please describe.
Does the pain limit your activities at work? Please describe.
Does the pain limit your walking? Please describe.
Does the pain limit your standing? Please describe.
Does the pain limit your sitting? Please describe.
Since your pain started, you stopped or limited the following activities:
Have you noticed any limitations in your strength or range of mobility in your arms or legs? Please describe.
What are your goals for physical therapy?
Are there any precautions, or contraindications to your PT treatment?
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