Med HX Body Pain ADL Form.doc 2026

The document is a medical history and pain assessment form for patients, capturing details about their diagnosis, treatment history, medications, and current pain levels. It includes questions about previous hospitalizations, surgeries, and other health conditions, as well as an evaluation of daily activities affected by pain. The patient is asked to rate their pain on a scale from 0 to 10 and indicate the nature of their pain through symbols. The form concludes with spaces for patient and therapist signatures.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information at the top of the form, including your name and date of birth.
In the 'Diagnosis' section, provide the diagnosis as stated by your physician along with the date of onset.
Answer the questions regarding hospitalization, surgeries, and previous treatments by selecting 'Yes' or 'No' and providing dates if applicable.
List any medications you are currently taking in the designated field. You can use the reverse side if more space is needed.
Indicate any past medical procedures such as EMG or MRI by circling them in the provided list.
Rate your pain on a scale from 0 to 10 for both best and worst experiences, filling in the respective fields.
Draw symbols representing your pain over the body diagram using our platform's drawing tools.
Check all activities you have difficulty performing due to pain in the final section of the form.
Finally, sign and date the form at the bottom before saving or sharing it directly from our editor.

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