• Empower Health PAIN & MOVEMENT Questionnaire

  • Please fill in all of the information below honestly and to the best of your ability.  

    This information will be kept strictly confidential as per ....

    When you get to the bottom of each page, click NEXT until you reach the end where leave your signature. Thank you!


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  • Please Print out the following diagram and use the following colour code to illustrate your pain:

    red  =  BURNING  |  blue  = SHARP  |  yellow = NUMBNESS/ TINGLING/ SHOOTING

    CIRCLE = areas of RESTRICTION or STIFFNESS

  • PLEASE PRINT THIS DIAGRAM AND BRING IT TO YOU WITH YOUR NEXT APPOINTMENT.  :)

  • My signature below affirms that I have answered the above as truthfully and completely as possible:

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