Rehabilitation Services Screening Form: Form reviewed with patient?    Yes/No            _______(therapist initials)

Name *
Name
Current Assesment of Pain *
0= No Pain, 2 = Mild Pain, 4= Moderate Pain, 6= Severe Pain, 8 = Very Severe Pain, 10 = Worst Possible Pain
Worst possible pain in the past week: *
0= No Pain, 2 = Mild Pain, 4= Moderate Pain, 6= Severe Pain, 8 = Very Severe Pain, 10 = Worst Possible Pain
Worst possible pain in the past month *
0= No Pain, 2 = Mild Pain, 4= Moderate Pain, 6= Severe Pain, 8 = Very Severe Pain, 10 = Worst Possible Pain
Least amount of pain in the last week: *
0= No Pain, 2 = Mild Pain, 4= Moderate Pain, 6= Severe Pain, 8 = Very Severe Pain, 10 = Worst Possible Pain
Least amount of pain in the last month: *
0= No Pain, 2 = Mild Pain, 4= Moderate Pain, 6= Severe Pain, 8 = Very Severe Pain, 10 = Worst Possible Pain
Have you recently noted any of the following? *
Have you ever smoked? *
Please list any injuries and/or surgeries you have had in the boxes below
Date Of Injury and/or surgery
Date Of Injury and/or surgery
Date of Injury and/or surgery
Date of Injury and/or surgery
Date of Injury and/or surgery
Date of Injury and/or surgery
Which of the following over the counter medications have you taken in the last 2 weeks? *
In the past three months, have you seen any of the following? *
Have you had any of the following procedures for this condition? *
Have you or any of your family members ever been diagnosed as having any of the following conditions?
Please check all that apply.
You *
A family Member *
By typing in your first and last name and today's date, you are saying that the information above is correct. *
By typing in your first and last name and today's date, you are saying that the information above is correct.
Today's Date
Today's Date