Description of Complaint:

Please describe briefly the area of the complaint.... Spine (Head, Neck, Upper back, Mid back, Low back, Across Hips) .... and/or Extremities (Shoulder, Arm, Elbow, Wrist, Hand, Hip, Leg, Knee, Ankle or Foot)

 

Cause of the Complaint: It developed from:

Work Related Activity Activity other than work Auto Accident An Injury Other Date of Injury:

 

Activities: Please check any items below that you are
unable to perform, or those that are painful, difficult or
which can only be performed in a limited manner:

Coughing or Sneezing Getting In-Out of Car Walking a short distance Standing 1 Hr plus Lying on side knees bent Lying flat on Stomach Lying flat on back

Bending Forward Turning Sitting at Table Dressing Self Sex Activity Balancing Kneeling

Sleeping Stooping Pushing Pulling Climbing Reaching Gripping

 

Check Other Symptoms

Blurring Vision Dizziness Fainting Confusion Convulsions Loss of Sleep Muscle Jerking

Numbness Tingling Weakness Buzzing or ringing in ears Depression or crying spells Headaches