Have you seen a Chiropractor Before? No Yes
Do you know what we do? No Yes
Is this visit the result of a work related accident or an auto accident? No Yes
Were you referred to us? No Yes
Who referred you to us?
Primary Care Physician (PCP)
PCP Phone
When did you last see a chiropractor?
Are you Pregnant? No No Yes
When did your symptoms start?
How did your symptoms begin?
How often do you experience your symptoms? Constantly (76%-100% of the day) Frequently (51%-75% of the day) Occasionally (26%-50% of the day) Intermittently (0%-25% of the day)
What describes the nature of your symptoms? Dull Ache Numb Shooting Burning Tingling
How are your symptoms changing? Getting Better Not Changing Getting worse
How much has the pain interfered with your normal work (including both work outside the home, and housework) Not at all A little bit Moderately Quite a bit Extremely
How much of the time has your condition interfered with your social activities? Not at all A little bit Moderately Quite a bit Extremely
In general how would you say your health right now is? Excellent Very Good Good Fair Poor
Who have you seen for your symptoms? No One Other Chiropractor Medical Doctor Physical Therapist Other
What treatment did you receive and when?
What test have you had for your symptoms? None X-Rays CT Scan MRI
When were they performed?
Have you had similar symptoms in the past? Yes No
If you have received treatment in the past for the same or similar symptoms, who did you see? None This Office Another Chiropractor Medical Doctor Physical Therapist Other
What is your Occupation? Professional/Executive White Collar/Secretarial Tradesperson Homemaker FT student Retired Other
if you are not retired, a homemaker, or a student, what is your current work status? Full Time Part Time Self-Employed Unemployed Off Work Other
What type of exercise do you perform? None Light Moderate Strenuous
Height
Weight
Headaches None Past Present
Neck Pain None Past Present
Upper Back Pain None Past Present
Mid Back Pain None Past Present
Low Back Pain None Past Present
Shoulder Pain None Past Present
Elbow/Upper Arm Pain None Past Present
Wrist Pain None Past Present
Hand Pain None Past Present
Hip/Upper Leg Pain None Past Present
Knee/Lower Leg Pain None Past Present
Ankle/Foot Pain None Past Present
Jaw Pain None Past Present
Joint Swelling/Stiffness None Past Present
Arthritis None Past Present
Rheumatoid Arthritis None Past Present
General Fatigue None Past Present
Muscular Incoordination None Past Present
Visual Disturbances None Past Present
Dizziness None Past Present
High Blood Pressure None Past Present
Heart Attack None Past Present
Chest Pains None Past Present
Stroke None Past Present
Angina None Past Present
Kidney Stones None Past Present
Kidney Disorders None Past Present
Bladder Infection None Past Present
Painful Urination None Past Present
Loss of Bladder Control None Past Present
Prostate Problems None Past Present
Abnormal Weight Gain/Loss None Past Present
Loss of Appetite None Past Present
Abdominal Pain None Past Present
Ulcer None Past Present
Hepatitis None Past Present
Liver/Gall Bladder Disorder None Past Present
Cancer None Past Present
Tumor None Past Present
Asthma None Past Present
Chronic Sinusitis None Past Present
Diabetes None Past Present
Excessive Thirst None Past Present
Frequent Urination None Past Present
Smoking/Use of Tobacco Products None Past Present
Drug/Alcohol Dependence None Past Present
Allergies None Past Present
Depression None Past Present
Systemic Lupus None Past Present
Epilepsy None Past Present
Dermatitis/Eczema/Rash None Past Present
HIV/AIDS None Past Present
Birth Control None Past Present
Hormonal Repleacement None Past Present
Pregnancy None Past Present
Other Health Problems/Issues
List all prescription and over-the-counter medications and nutrirional/herbal supplements you are taking:
List all surgical procedures you have had and times you have been hospitalized:
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