Name
First Name
Last Name
Date of Birth
Date (DD)
Month (MM)
Year (YYYY)
State / Province
Age
Email
example@example.com
Has your address changed since your last visit?
Yes
No
Has your insurance coverage changed since your last visit?
Yes
No
Occupation:
Where is your pain located?
When did this pain begin (Specific date if possible):
/
Month
/
Day
Year
Date
Was the pain result of a:
Work Injury
Car Accident
Other
Is the pain getting better or worse?
Better
Worse
Staying the Same
When Does the pain occur:
Do you experience pain when you cough?
Yes
No
What is the quality of pain?
Sharp
Dull
Achy
Stabbing
Shooting
Severity of Pain
0 (No Pain)
1
2
3
4
5
6
7
8
9
10 (Severe)
When is the pain better?
Morning
Afternoon
Evening
Night
All Day
When is the pain worse?
Morning
Afternoon
Evening
Night
All Day
Does the pain travel to any other parts of the body?
Yes
No
If yes, where?
Are you experiencing numbness or tingling sensations?
Yes
No
If yes, where?
What makes the pain better?
What makes the pain worse?
Which health care providers have you seen since your last visit to our clinic?
Family Doctor
Chiropractor
Massage Therapist
Physiotherapist
Acupuncturist
Chiropodist
Specialist
Other
Are you on any medication?
Yes
No
Have you fractured or dislocated any bones?
Yes
No
Have you been diagnosed with any medical conditions?
Yes
No
Have you been admitted to the hospital since your last visit to our clinic?
Yes
No
Have you had any significant health changes since your last visit?
Yes
No
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