United Health Care Authorization

United Health Care Authorization form
3a. Average pain intensity in the last 24 hours. (Choose 1) *
3b. Average pain intensity in the last week. (Choose 1) *
4. How often do you experience your symptoms? *
5. How much have your symptoms interfered with your daily activities? *
6. How is your condition changing, since care began at this facility? *
7. In general , would you say your overall health right now is… *
Has your back pain spread down your leg(s) at some time in the last 2 weeks? *
Have you had pain in the shoulder or neck at some time in the last 2 weeks? *
Have you only walked short distances because of your back pain? *
In the last 2 weeks, have you dressed more slowly than usual because of back pain? *
Do you think it’s not really safe for a person with a condition like yours to be physically active? *
Have worrying thoughts been going through your mind a lot of the time? *
Do you feel that your back pain is terrible and it’s never going to get any better? *
In general have you stopped enjoying all the things you usually enjoy? *
Overall, how bothersome has our back pain been in the last 2 weeks? *
By checking the box, I acknowledge the information provided is correct. *

This form is collected for current group numbers requiring Authorization from United Health Care.