Patient Symptoms Form Patient Symptoms Form Patient ID:* Enter the last 4 digits of your phone numberCurrent Symptoms Joint pain Joint stiffness Back pain Fatigue Dislocated joints Dizziness Poor balance Clicking joints Recurrent joint injuries Digestive issues Thin Skin Stretchy skin Other If Other, describe hereDate your symptoms began* Month Day Year Please select the location of your symptoms (pick as many as needed):* Neck Upper back Upper extremities Middle back Lower back Lower Extremities Please select any of the following words that describe the symptoms: Sharp Stabbing Burning Ache Tingling Numb If Other, describe hereMy symptoms currently:* Come and go Are constant Change with activity Select your current average pain level*0123456789100= No pain 10 = Maximum Pain LevelPlease identify the goals you would like to achieve:*
