Arthritis/swollen joints GoutAsthma, Bronchitis, or Emphysema High Blood PressureAngina, Coronary Heart Disease Heart Attack or SurgeryAnemia Infectious Diseases (i.e. ActiveTuberculosis)Bowel/Bladder Problems OsteoporosisBreathing difficulties/Shortness of breath PacemakerBlood Clot/Emboli Psychological/Emotional ProblemsCancer or Chemotherapy/Radiation Problems SleepingDiabetes Stroke/TIAEpilepsy/Seizures Thyroid Problems

0 - No pain ever1 -2 - Mild pain3 -4 -5 - Moderate pain6 -7 -8 - Severe pain9 -10 - Worst pain

Anti-inflammatoryMuscle RelaxersPain MedicationsOther


YesNo


YesNo


YesNo

YesNo

YesNo




Physical TherapyOccupational TherapyMassageChiropractorMRIX-RaysCT ScanEMG/NCVNeurologistOrthopedistGeneral PractitionerPodiatristMyelogramOther


Full TimePart TimeModified DutyNot workingRetired




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