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 you have had in the boxes below
Date Of Injury
Date Of Injury
Date of Injury
Date of Injury
Date of Injury
Date of Injury
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