United Health Care Authorization United Health Care Authorization form If you are human, leave this field blank. Last Name * Date of Birth * Date Symptoms Began on: * 1. Briefly describe your symptoms (be specific as possible including where on your body the pain is): * 2. How did your symptoms start? (any cause of the current symptoms or activities that make it worse) * 3a. Average pain intensity in the last 24 hours. (Choose 1) * 0 No Pain 1 2 3 4 5 Moderate Pain 6 7 8 9 10 Worst Pain 3b. Average pain intensity in the last week. (Choose 1) * 0 No Pain 1 2 3 4 5 Moderate Pain 6 7 8 9 10 Worst Pain 4. How often do you experience your symptoms? * Constantly (76%-100% of the time) Frequently (51%-75% of the time) Occasionally (26%-50% of the time) Intermittently (0%-25% of the time) 5. How much have your symptoms interfered with your daily activities? * Not at all A little bit Moderately Quite a bit Extremely 6. How is your condition changing, since care began at this facility? * N/A- This is the initial visit Much worse Worse A little worse No change A little better Better Much better 7. In general , would you say your overall health right now is… * Excellent Very good Good Fair Poor Has your back pain spread down your leg(s) at some time in the last 2 weeks? * Yes No Have you had pain in the shoulder or neck at some time in the last 2 weeks? * Yes No Have you only walked short distances because of your back pain? * Yes No In the last 2 weeks, have you dressed more slowly than usual because of back pain? * Yes No Do you think it’s not really safe for a person with a condition like yours to be physically active? * Yes No Have worrying thoughts been going through your mind a lot of the time? * Yes No Do you feel that your back pain is terrible and it’s never going to get any better? * Yes No In general have you stopped enjoying all the things you usually enjoy? * Yes No Overall, how bothersome has our back pain been in the last 2 weeks? * Not at all Slightly Moderately Very much Extremely By checking the box, I acknowledge the information provided is correct. * I agree Initials: * Date Form Completed: * Submit This form is collected for current group numbers requiring Authorization from United Health Care.