CECIL CHIROPRACTIC

Patient ID#______ACTIVITIES OF DAILY LIVING Date______

Describe your condition: ______

Is this problem getting better worse not changing? How does it make you feel? ______

Has this problem affected your work activities? Not at all A little bit Moderately Quite a bit Extremely

How? ______

Has this problem affected your family activities? Not at all A little bit Moderately Quite a bit Extremely How?______

Has this problem affected your social activities? Not at all A little bit Moderately Quite a bit Extremely How?______

Has this problem affected your recreational activities? Not at all A little bit Moderately Quite a bit Extremely How?______

Has this problem affected your self-esteem? Not at all A little bit Moderately Quite a bit Extremely

How? ______

MODIFYING FACTORS: Since the time you began suffering from this problem, what have you tried or who has helped you?

(Ex: Chiropractic,Exercise, Nutrition, Over the Counter Medicines, Prescriptions, Surgery, Therapy, Home Remedies)

What? ______Who?______

How much?______HowOften?______

Prior to your condition, how long could you both previously and now presently perform these functional activities:

BEFORE NOW BEFORE NOW

Sit continuously _____ hr ____ min _____ hr ____ min Drive continuously _____ hr ____ min _____hr_____min

Stand continuously _____ hr ____ min _____ hr ____ min Walk continuously _____ hr ____ min _____ hr ____min

Lay continuously ______hr ____ min _____ hr ____ min Work continuously _____ hr _____min _____ hr____min

On a scale of 0-10, where 0 is nodysfunctionand 10 is extreme dysfunction, rate yourimpairmentat its worst.

Level of ImpairmentDue to Symptoms (Resting):

______

0 1 2 3 4 5 6 7 8 9 10

Level of Impairment Due to Symptoms (With Activity):

______

0 1 2 3 4 5 6 7 8 9 10

What activities would you like to be doing again as a result of your treatment? 1.______

2.______

3.______

How does this problem keep you from doing these activities?______

Please list any concerns that could interfere with your commitment to treatment? (Time, Transportation, Other) Specify:______

Since your last visit in this office, have you had any accidents, injuries, illnesses, surgeries, hospitalizations, diagnosed medical conditions or changes in medication? Please Explain: ______

Lifestyle Habits:

How do you rate your pain? improving worsening _____% where______no change where______

How do you rate your function? improving worsening _____% where______no change where______

How do you rate your sleep? improving worsening _____% where______no change where______

How do you rate your stress? improving worsening _____% where______no change where______

How do you rate your posture? improving worsening _____% where______no change where______

How do you rate your exercise? improving worsening _____% where______no change where______

How do you rate your diet? improving worsening _____% where______no change where______

How do you rate your health? improving worsening _____% where______no change where______

Patient Name ______Signature______Date______