Tele-health Check-in
Fields with
*
are required
We are doing our best to stay connected with patients during the Covid-19 crisis. Your health and wellbeing is important to us. Your doctor has requested that you please complete this brief form (Takes 5 minutes) and click submit. We will call you within 48 hours to check-in. Thank you.
Name
Which doctor/provider do you usually see?
Email
Phone (Best number to call you on)
Insurance Type
None
PPO
HMO
Medicare
Workers Comp
Other
Q 1.1. On a scale of 0 - 10, how intense is your physical pain (0 no pain, 10 worst pain)
0
1
2
3
4
5
6
7
8
9
10
Q 1.2. On a scale of 0 - 10 describe how intense your emotional pain feels (0 no pain, 10 worst pain)
0
1
2
3
4
5
6
7
8
9
10
Q 1.3. How many times have you been to the emergency room or hospital in the last 60 days because of pain?
0
1
2
3
4
5
6
7
8
9
10
More than 10
Q 2.1. How often do you feel nervous, anxious or on edge?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 2.2. How often are you not able to stop worrying?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 2.3. How often do you find yourself worrying to much?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 2.4. How often do you have trouble relaxing?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 2.5. How often do you feel restless?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 2.6. How often do you feel irritable?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 2.7. How often do you feel afraid as if something awful might happen?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 3.1. How often do you find yourself feeling little interest or pleasure in doing things?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 3.2. How often do you find yourself feeling down, depressed or hopeless?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 3.3. How often do you find yourself having trouble sleeping?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 3.4. How often do you feel tired or have low energy?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 3.5. How often do you find yourself having poor appetite or overeating?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 3.6. How often do you find yourself feeling bad about yourself, like you are a failure or have let yourself or your family down?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 3.7. How often do you have trouble concentrating on things such as reading or watching television?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 3.8. How often do you find yourself moving very slowly or feeling fidgety and restless?
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q. 3.9. How often do you find yourself thinking you would be better off dead or hurting yourself in some way?
Please alert your doctor today if this is an issue for you
1) Not at all
2) 1 or 2 days per week
3) More than 4 days per week
4) Nearly every day
Q 4.1 What is your typical pain intensity?
1) I have no pain at the moment
2) The pain is very mild at the moment
3) The pain is moderate at the moment
4) The pain is fairly severe at the moment
5) The pain is very severe at the moment
6) The pain is the worst pain imaginable at the moment
Q. 4.2 How does pain effect your ability to care for yourself?
Please alert your doctor today if this is an issue for you
1) I can look after myself
2) I can but it causes some pain
3) I can but it causes severe pain
4) I need some help
5) I need help every day
6) I cannot leave bed or wash
Q. 4.3 How does pain effect your ability to lift objects
Please alert your doctor today if this is an issue for you
1) I can lift heavy weights without extra pain
2) I can lift heavy weights but it gives extra pain
3) Pain prevents me from lifting heavy objects off the floor
4) Pain prevents me from lifting light objects off the floor
5) I can only lift very light weights
6) I cannot lift or carry anything at all
Q. 4.4 How does pain effect your mobility?
Please alert your doctor today if this is an issue for you
1) I can walk any distance
2) I can barely walk 1 mile
3) I can barely walk 1/2 mile
4) I can barely walk 100 yards
5) I need a stick or crutches
6) I am in bed most of the time
7) I use a wheelchair
Q. 4.5 How does pain effect your ability to sit?
Please alert your doctor today if this is an issue for you
1) I can sit as long as I like
2) I can almost sit as long as I like
3) I can barely sit for 1 hour
4) I can barely sit for 30 minutes
5) I can barely sit for 10 minutes
6) Pain prevents me from sitting
Q. 4.6 How does pain effect your ability to stand?
Please alert your doctor today if this is an issue for you
1) I can stand as long as I want
2) I can stand but with extra pain
3) I can barely stand for 1 hour
4) I can barely stand for 30 minutes
5) I can barely stand for 10 minutes
6) I cannot stand at all
Q. 4.7 How does pain effect your sleep?
Please alert your doctor today if this is an issue for you
1) I sleep perfectly well
2) My sleep is occasionally effected
3) I sleep less than 6 hours
4) I sleep less than 4 hours
5) I sleep less than 2 hours
6) Pain prevents me from sleeping at all
Q. 4.8 How is your social life affected by pain?
Please alert your doctor today if this is an issue for you
1) My social life is normal
2) My social life causes some pain
3) Pain limits any sport etc
4) I go out but not very often
5) I am mostly stuck at home
6) I have no social life because of pain
Q. 4.9 How does pain effect your ability to travel?
Please alert your doctor today if this is an issue for you
1) I can travel anywhere
2) Travel gives me a little pain
3) I can barely travel two hours
4) I can barely travel one hour
5) I can barely travel 30 minutes
6) I cannot travel
Submit Form