Neck low back hips, legs, and feet



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NECK LOW BACK HIPS, LEGS, AND FEET


___ Pain ___ Low back pain ___ Pain in buttocks (R/L)

___ Neck pain with movement ___ upper lumbar ___ pain in hip joint (R/L)

___ forward ___ lower lumbar ___ pain down leg (R/L)

___ backward ___ Sacroiliac pain ___ Pain down both legs

___ turning to the left ___ Low back pain is worse when ___ Knee pain (R/L)

___ turning to the right ___ working ___ Leg cramps (R/L) ___ bending to the left ___ lifting ___ Cramps in feet (R/L)

___ bending to the right ___ stooping ___ Pins & needles in legs (R/L)

___ Pinched nerve in neck ___ standing ___ Numbness of leg (R/L)

___ Neck feels out of place ___ sitting ___ Numbness of feet (R/L)

___ Muscle spasms in neck ___ bending ___ Numbness of toes (R/L)

___ Grinding sounds in neck ___ coughing ___ Feet feel cold (R/L)

___ Popping sounds in neck ___ lying down (sleeping) ___ Swollen ankles (R/L)

___ Arthritis in neck ___ walking ___ Swollen feet (R/L)

___ Swollen glands ___ other

___ Pain relieved with THERAPEUTIC TECHNIQUES

SHOULDERS ___ ice ___ Acupuncture

___ Pain in shoulder joint (R/L) ___ heat ___ Herbal Medicine

___Pain across shoulders ___movement ___ Homeopathy/Bach Flower

___ Bursitis (R/L) ___ physical therapy ___ Hellerwork

___ Arthritis (R/L) ___ topical analgesics ___ Rolfing/Structural

___ Can’t raise arm ___ medications integration

___ above shoulder level ___ other ___ Massage

___ over head ___ Slipped disk ___ Chiropractic

___ Can’t put arm behind back ___ Low back feels out of place ___ Psychotherapy (Optional)

(as if putting on a bra) ___ Muscle Spasms ___ Visualization/Guided

___ Tension in shoulders imagery

___ Pinched nerve in shoulder (R/L) ___ Biofeedback

___ Muscle spasms in shoulders ___ Feldenkrais

___ Polarity



ARMS AND HANDS ___ Reiki

___ Pain in upper arm (R/L) ___ Tragerwork

___ Pain in elbow (R/L) ___ Craniosacral Therapy

___ Movement aggravates pain ___ Physical Therapy

___ Pain in forearm (R/L) ___ Therapeutic Exercise

___ Pain in hands (R/L) ___ Movement Therapy

___ Pain in fingers (R/L) ___ Nutrition

___ Feeling of pins & needles in arms (R/L) ___ Other ____________

___ Feeling of pins & needles in fingers (R/L)

___ Numbness in arms (R/L)

___ Numbness in fingers (R/L)

___ Fingers go to sleep (R/L)

___ Hands cold (R/L)

___ Swollen joints in fingers (R/L)

___ Arthritis in fingers (R/L)

___ Loss of grip strength (R/L)


MID-BACK & CHEST


___ Mid-back pain

___ Pain between shoulder blades

___ Sharp stabbing pain

___ Dull ache

___ Pain from front to back

___ Muscle spasms in mid back

___ Pain in kidney area

___ Chest pain Please indicate



___ Shortness of breath by shading where

___ Pain around ribs you have pain.


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