Back Injury Recovery Program:  Chart Form

Name;
Home address:
Home telephone number:

Name of primary care provider:

Providers telephone number:

Visit Number: 1  2  3  4

Pain Assessment

Ask the worker to rate their pain right now using 0 as no pain and 10 as the worst pain possible-unbearable. Record this rating. Ask the worker to list two or three things they have noticed make their pain worse---then to list two to three things that help relieve their pain.

Ask the worker to rate their ability to perform their daily home activities right now. Zero represents no problems with daily activities and 10 representing unable to move at all due to low back problems. Record this rating.

0=no problems with home activities due to low back pain

10=unable to do any home activities due to low back pain

Rating:

Ask the worker to rate their ability to perform their daily work activities right now. Zero represents no problems with daily activities and 10 representing unable to move at all due to low back problems. Record this rating.

0=no problems with home activities due to low back pain

10=unable to do any home activities due to low back pain

Rating:

Also complete Health Goal Form each visit.