Review Form

We genuinely appreciate your time and effort in completing this review form. Your feedback is instrumental in understanding your current health status, which in turn, aids us in customizing a more effective care plan for you. By sharing your experiences, you play a pivotal role in your healthcare journey, ensuring that we can provide the most supportive and beneficial care. Thank you for your active participation and for sharing your valuable insights.

PERSONAL INFORMATION

PAIN LOCATIONS Please specify the area(s) where you feel pain.

Please rate your pain at its WORST in the last 24 hours (0 = No pain, 10 = Pain as bad as you can imagine):

Please rate your pain at its LEAST in the last 24 hours (0 = No pain, 10 = Pain as bad as you can imagine):

On AVERAGE, how would you rate your pain in the last 24 hours (0 = No pain, 10 = Pain as bad as you can imagine):

RIGHT NOW, how would you rate your pain in the last 24 hours (0 = No pain, 10 = Pain as bad as you can imagine):

In the past 24 hours, how much RELIEF have pain treatments or medications provided? (0 = No relief, 10 = Complete relief)

Please rate how, during the past 24 hours, pain has INTERFERED with your:

A. General Activity (0 = Does not interfere, 10 = Completely interferes)

B. Mood (0 = Not experiencing any symptoms of anxiety or depression, 10 = Being severely affected)

C. Walking Ability (0 = no limitation in mobility, 10 = unable to move around)

D. Normal work (Includes both work outside the home and housework)
(0 = Unable to engage in any, 10 = Fully engage in all usual activties)

E. Relation with other people (0 = Does not interfere, 10 = Completely interferes)

F. Sleep (0 = Does not interfere, 10 = Completely interferes)

G. Enjoyment of life (0 = Does not interfere, 10 = Completely interferes)

CURRENT MEDICATIONS
Please list any medications you are currently taking along with the dosage.

SLEEP PATTERNS On average, how many hours of sleep do you get per night and how would you describe the quality of your sleep?

IMAGING and RADIOLOGY Have you had any recent scans like an MRI or CT since last visit? If yes, could you please specify the body part examined and which radiology practice did you visit for these scans? (e.g., IMED, Castlereagh, Lumus)

Your Overall Health Today: We would love to know your perspective on your overall health today. On a scale from 0 to 100, with 100 being the best health you can imagine and 0 being the worst, how would you rate your health today?

ADDITIONAL INFORMATION

We value your insights and experiences. If there's anything more you'd like to share or discuss, please feel free to write it down here. Your additional information can be instrumental in providing you a tailored care plan.