Rehab Exercise Plan

Is your main issue pain or injury?

Where is the pain or injury located?

How long have you had this pain or injury?

How intense is your pain? (0 = no pain, 10 = worst)

5

How did it start?

What makes it worse? (optional) What makes it better? (optional)

Have you had any previous treatment? (optional) Any swelling, bruising, instability, or locking? Any of the following? (Check all that apply)

Do you have any other medical issues? (optional, e.g. diabetes, heart disease, epilepsy, pregnancy, recent surgery, cancer, osteoporosis, etc.)