CONFIDENTIAL PATIENT INFORMATION    Please fill out the form completely Legal Name Home Phone Physical Address - No PO Boxes City Zip E-mail Address Social Sec. No. Birthdate (00/00/00): Age     Marital Status Occupation Employer Employer Address City Zip               Employment Phone Can you receive calls at work? Yes No CURRENT COMPLAINTS 1. Date Began                                                 2. Date Began                                                 3. Date Began Treatment received for these complaints: Meds Lab Tests XRays MRI                                                                         Physical Therapy Surgery None                                                                         Other Dr.s Name: in the city of Phone How did your pain start? Accident at Home Accident at Work Activity At Home                                              Activity at Work Woke Up With It It's Always Been There                                              Other Your pain bothers you most when you: Sit Stand Walk Sleep Drive                                                                       Bend Reach                                                                       Other You are most comfortable when you: Sit Stand Walk Sleep Drive                                                                   Other WORK ENVIRONMENT You work hours/day days/week. You sit % of the time. You stand % of the time. You bend % of the time. You use a computer % of the time. The monitor is directly in front of you Yes No You use a phone % of the time. You use a headset Yes No. You lift approx. lbs. at a time times/day. You drive hours/day. HOME ENVIRONMENT You are home days / week. You spend most of that time Your recent home project has been Your favorite activities are PRINT this page and then go on to Page 2.