Please list any surgeries, injuries, or other conditions for which you have been hospitalized, including approximate date and reason for surgery or hospitalization:

Date Reason for Surgery/Hospitalization

Current Medications

Please include all prescriptions, over-the counter medications, herbal and vitamin/mineral/dietary (nutritional) supplements with each medication's name, dosage, frequency and administered route (oral, injection, etc).

Medication Dosage How often Reason for taking

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Pain Scale

Please rate your current level of pain. Circle the corresponding number on chart. During our evaluation we will discuss the minimum and maximum pain levels you have been experiencing throughout your painful time.

No pain Moderate pain Worst possible pain

Fall Assessment

Have you experienced 2 or more falls in the past year or any fall with injury in the past year? If yes please list if fall was with or without injury.