FILL & PRINT • PATIENT WORKSHEET

Pain & activity worksheet

Track your symptoms and the everyday activities that matter to you. Discuss your answers with your therapist.

Your answers are not submitted.

Fill out what you can, then print or save as PDF using your device’s print menu. Bring it to your visit. Nothing is sent to Swift. Closing or refreshing this page can clear your work.

Swift Rehabilitation, Inc.Maryland: (443) 323-0027 / (443) 469-3426 · New Jersey: (856) 856-4122

Original discussion worksheet

This is not the ODI, NDI, KOOS, or another validated outcome measure. It has no diagnostic score. Bring it to your therapist to discuss changes over time.

Name (optional)DateArea of concernSide / locationCurrent discomfort (0 = none, 10 = worst imaginable)When did symptoms begin?What seems to increase or ease symptoms?Walking, stairs, sitting, sleep, or self-care: what has changed?Activity goal 1 and what you can do todayActivity goal 2 and what you can do todayActivity goal 3 and what you can do todayChanges since your last visit / questions for your therapist

Patient / representative signature: ___________________________________

Date: ____________________ Relationship (if applicable): ____________________

This worksheet is for discussion with Swift. It does not confirm an appointment, establish treatment consent, or authorize release of records.

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