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- Fill in your employer details and primary care physician's information. This section is crucial for coordinating your healthcare services.
- Indicate where you experience pain by marking an 'X' on the provided diagram. This visual representation helps convey your symptoms clearly.
- Describe your current problem and how it began in the designated text area. Be specific about the onset and nature of your symptoms.
- Rate your current pain level on a scale from 0 (no pain) to 10 (unbearable pain). This helps healthcare providers understand the severity of your condition.
- Complete the sections regarding past medical history, including any relevant tests like X-rays or MRIs, and check all applicable health issues.
- Finally, review all entered information for accuracy before signing and dating the form at the bottom.
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