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EAST EARL CHIROPRACTIC, 4607 DIVISION HIGHWAY, EAST EARL, PA 17519

EAST EARL CHIROPRACTIC, 4607 DIVISION HIGHWAY, EAST EARL, PA 17519-2025

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The document is a patient assessment form from East Earl Chiropractic, designed to evaluate a patient's baseline condition before treatment. It includes sections for pain level measurement using a visual analog scale, difficulties in daily activities, and pre-existing conditions related to neck or back issues. Patients are required to provide personal information, indicate their pain levels, and circle activities they find challenging.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name and the date in the designated fields at the top of the form. This personal information is essential for your records.
In the 'Attending DR' section, specify your attending doctor’s name to ensure proper documentation of your care.
Utilize the Visual Analog Scale to indicate your pain level. Write down each body area affected and rate your pain from 0 (no pain) to 10 (unbearable pain).
For Activities of Daily Living, circle all activities that you found difficult. This helps in assessing how your condition affects daily tasks.
Circle any pre-existing conditions related to neck or back issues. This information is crucial for a comprehensive evaluation.
Finally, sign and date the form at the bottom to confirm that all information provided is accurate.

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Versions	Form popularity	Fillable & printable
2007	4.8 Satisfied (24 Votes)

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