PROGRESS EVALUATION III
Comprehensive Patient Progress Evaluation
Patient Name *
Date
Pain Ratings (0 = No Pain, 10 = Worst)
Current pain level (0–10)
0
1
2
3
4
5
6
7
8
9
10
Pain level when care started (0–10)
0
1
2
3
4
5
6
7
8
9
10
Best pain level (lowest) (0–10)
0
1
2
3
4
5
6
7
8
9
10
Worst pain level (highest) (0–10)
0
1
2
3
4
5
6
7
8
9
10
Daily Activity Limitations
How does pain/condition limit the following?
Work / daily activities
None
Mild
Moderate
Severe
Sleep
None
Mild
Moderate
Severe
Exercise / physical activity
None
Mild
Moderate
Severe
Social activities
None
Mild
Moderate
Severe
Family activities
None
Mild
Moderate
Severe
Health Challenges
Current health challenges
Progress on health challenges
Programs
Programs completed
Programs ongoing
Program satisfaction (0–10)
0
1
2
3
4
5
6
7
8
9
10
Lifestyle Changes
Lifestyle changes made
Have lifestyle goals been met?
Yes
No
Overall satisfaction with care (0–10)
0
1
2
3
4
5
6
7
8
9
10
Would patient recommend this practice?
Yes
No
Additional Notes
Signatures
Patient Signature *
Sign here with your finger or stylus
Provider/Doctor Signature
Sign here with your finger or stylus
Submit Progress Evaluation III