Dr. Gerald B Harris, II

Patient Name * Date of Birth * Date *

History of Symptoms:

1. Please check the following symptoms that you have * 2. When did your symptoms begin? 3. Are you experiencing any problems controlling your bladder or bowels? * 4. Do you wake up at night because of your pain? * 5. What makes your pain better? * 6. If "other" please explain 7. What makes your pain worse? * 8. Are you currently working? *

Past Treatment History

9. Have you ever had back or neck pain before? * 10. If "yes", When? 11. Have you had back or neck surgery? * 12. What receint diagnostic tests have you had? * 13. Have you have any of the following treatments for your pain? * 14. Did the treatments help? 15. Rate your pain on a scale of 1 to 10, with 1 being no pain and 10 the most severe pain *