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Occupational Therapy Pre-Exam Questionnaire

In order to evaluate your condition fully, please be as accurate as possible.  Thank you.

  1.  What is your Age?  __________

2.  What is your gender?   ____ Male    ____ Female

3.  What is your occupation?  _______________________________________________________________________________________________________

4.  Are you working now?  ___ Yes    ___ No

5.  Have you had occupational therapy before?    ___ Yes      ___ No

6.   What is your pain/problem?  _____________________________________________________________________________________________________

7.   What caused your pain/problem? __________________________________________________________________________________________________

8.   Approximately when did it start? (date) __________________

9.   Is it getting worse, better or staying the same?  ________________________________________________________________

10.  Have you ever had this problem/pain before?  __________________________________________________________________

11. Is your pain constant (never goes away)? ___________________________________________________________________________________________

12. On the scale below circle your worst pain level in the past couple of days.

Mild            Moderate                   Severe

0….1….2….3….4….5….6….7…..8….9…..10

13.  Are you taking any medication for this pain/problem?    ___ Yes   ___ No

If yes does it help? ____________________________________________________________________________________________________________

14.   Are any of your usual everyday activities affected?  ___ Yes   ___ No

15.  List all past surgeries with dates:  ________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

16.  List all medical conditions you have (or were told you have? ______________________________________________________________________________

__________________________________________________________________________________________________________________________

 

Patient Name:  __________________________________

Signature:  _____________________________________                                Date:  ______________________

 

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