Re-Examination Form

PLEASE FILL OUT EVERY REQUIRED FIELD IN THIS FORM, IF NOT YOU WILL BE TAKEN BACK TO THE TOP OF THE PAGE.

Progress Evaluation

In the current rating fields, please rate the pain that you are currently experiencing on a scale of 0-10, 10 being the worst pain and 0 being none. Under frequency and improvement, please check all boxes that apply.

Head Pain: Frequency and Improvement*
Please select at least one option
Neck: Frequency and Improvement*
Please select at least one option
Mid-Back: Frequency and Improvement*
Please select at least one option
Shoulder: Frequency and Improvement*
Please select at least one option
Ribs: Frequency and Improvement*
Please select at least one option
Low-Back: Frequency and Improvement*
Please select at least one option
Others: Frequency and Improvement*
Please select at least one option
When you first began care at this office, you indicated a limiting ability to perform some daily activities; please identify if your current condition is affecting your ability to carry out any of the activities listed below:*
Please select at least one option
How would you rate your improvement?*
Please select at least one option

Low Back Disability Index

This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to mange in everyday life. Please answer every section and mark in each section only one box that applies to you. 

Section 1 - Pain Intensity
Section 2 - Personal Care
Section 3 - Lifting
Section 4 - Walking
Section 5 - Sitting
Section 6 - Standing
Section 7 - Sleeping
Section 8 - Social Life
Section 9 - Traveling
Section 10 - Changing Degree of Pain

Neck Disability Index

This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to mange in everyday life. Please answer every section and mark in each section only one box that applies to you.

Section 1 - Pain Intensity
Section 2 - Personal Care
Section 3 - Lifting
Section 4 - Reading
Section 5 - Headaches
Section 6 - Concentrating
Section 7 - Work
Section 8 - Driving
Section 9 - Sleeping
Section 10 - Recreation

Thank you for taking the time to fill out this form.

Our Location

950 Yale Ave, Suite 29. Wallingford, CT 06492

Office Hours

Open Monday through Thursday

Monday:

8:00 am-9:30 am

3:00 pm-5:00 pm

Tuesday:

3:00 pm-6:00 pm

Wednesday:

10:00 am-11:00 am

3:00 pm-6:00 pm

Thursday:

3:00 pm-6:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed