Liza Pain Management Center

Initial Evaluation

Patient history and chief complaint

Gather information about the patient's current symptoms, medical history, and any relevant family history.

1. Personal Information

Full Name:

Email:

Phone Number:

Age:

Gender: Male Female Other

2. Pain Location

Where is your pain? (Select all that apply) Lower Back Tailbone Area One-Sided Hip Left Legs Right Leg From Back to Foot Buttock Area Thighs or Calves Feet or Toes

3. Pain Description

How would you describe your pain? (Select all that apply) Dull Ache Sharp/Stabbing Burning Tingling or Pins and Needles Throbbing Electric Shock Muscle Stiffness or Tightness

4. Pain Trigger

When do you feel more pain? (Select all that apply) While Sitting While Standing While Walking While Bending Forward While Bending Backward After Lifting Weight While Lying Down While Turning in Bed While Coughing/Sneezing

5. Pain Duration

How long have you had this pain?

6. Radiating Pain

Does the pain travel to your legs or feet? Yes, Left Leg Yes, Right Leg No, it’s Localized Both Legs

7. Associated Symptoms

Do you feel any of these symptoms with pain? (Select all that apply) Numbness Weakness in Leg/Foot Loss of Balance Difficulty Walking Foot Drop Loss of Bladder/Bowel Control

8. Pain Relief

What improves or reduces your pain? (Select all that apply) Rest Movement Lying Down Heat or Ice Medication Acupuncture Exercise or Stretching

9. Medical History

Do you have any of the following history? (Select all that apply) Past Spine Injury Disc problem Spondylolisthesis Surgery on Back Heavy Lifting Job Sedentary Lifestyle Obesity Diabetes or High Blood Pressure Heavy Lifting Job

10. Posture & Mobility

Posture or mobility-related issues ?

11. Red Flag Symptoms

Are there any Related Red Flag Symptoms? Fever with back pain Weight loss Pain at night waking you up History of cancer Bladder or bowel issues Sudden unexplained weakness

12. Neurological Assessment

Do you experience numbness or tingling in your legs or feet? Yes No

Is there a loss of sensation in specific areas? Yes No

Have you noticed weakness in your legs or feet? Yes No

Is there difficulty in lifting your foot (foot drop)? Yes No

Have you observed changes in your reflexes? Yes No

Do you feel unsteady while walking? Yes No

Have you experienced falls due to loss of balance? Yes No

13. Structural Assessment

Do you have a noticeable curvature in your spine (scoliosis)? Yes No

Is there an exaggerated inward curve in your lower back (lordosis)? Yes No

Do you feel that one side of your pelvis is higher than the other? Yes No

Is there a forward or backward tilt in your pelvis? Yes No

Do you suspect one leg is shorter than the other? Yes No

14. Functional Movement

Can you bend forward to touch your toes without pain? Yes No

Is bending backward painful or restricted? Yes No

Do you limp or have an altered walking pattern? Yes No

Is your stride length shorter than usual? Yes No

Is it difficult to rise from a seated position without using your hands? Yes No

15. Surgical History

Have you ever had spine surgery? Yes No

If yes, What type? (if no choose NO) Discectomy Laminectomy Fusion No

Do you have any metal implants or screws in your spine? Yes No

Was the surgery helpful or did symptoms come back? Yes No Never had Surgery

Do you feel pain around the surgical area? Yes No Never had Surgery

16. Pain Scale & Daily Impact

Pain level now on a scale from (0–10) ? Mild (0 - 3) Moderate (4 - 6) Severe (7 - 10)

Pain in the morning on a scale from (0–10) ? Mild (0 - 3) Moderate (4 - 6) Severe (7 - 10)

Pain at night on a scale from (0–10) ? Mild (0 - 3) Moderate (4 - 6) Severe (7 - 10)

How much does pain interfere with daily work on a scale from (0–10) ? Mild (0 - 3) Moderate (4 - 6) Severe (7 - 10)

How much does pain interfere with sleep on a scale from (0–10) ? Mild (0 - 3) Moderate (4 - 6) Severe (7 - 10)

17. Inflammatory & Autoimmune

Do symptoms get worse in the morning but improve with movement? Yes No

Do you feel stiffness lasting more than 30 minutes after waking up? Yes No

Do you have joint pain elsewhere (shoulders, hips, knees)? Yes No

Any history of psoriasis, eye inflammation, or ulcerative colitis? Yes No

18. Mental & Emotional Impact

Do you feel depressed or anxious due to your pain? Yes No

Are you afraid to move because it might hurt more? Yes No

Do you avoid social or work activities due to your spine issues? Yes No

19. Lifestyle & Sleep

Do you sleep well at night? Yes No

What posture do you usually sleep in? On my back with proper support On my side with proper support On my stomach Frequently changing positions without specific support

Do you sit for long hours at work or during the day? Yes No

Do you take regular walking or stretching breaks? Yes No

Other Information (optional):

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