Patient Intake
Name:
Date:
-
Month
-
Day
Year
Mark Where You Are Having Symptoms:
Please Select Those Where You Are Having Symptoms?
Neck Pain
Low Back Pain
Headache
Left / Right Blurry Vision
Left / Right Shoulder Pain
Left / Right Hand Pain
Left / Right Hip Pain
Left / Right Foot Pain
Left / Right Rib Pain
Left / Right Arm Numb
Left / Right Leg Numb
Vertigo
Left / Right Ear Ringing
Left / Right Elbow Pain
Left / Right Arm Pain
Left / Right Knee Pain
Left / Right Leg Pain
Chest Pain
Mid Back Pain
Left / Right Sciatica
Short Term Memory Loss
Left / Right Jaw Pain
Left / Right Wrist Pain
Stomach Pain
Left / Right Ankle Pain
Left / Right Leg Cuts/Bruise
Left / Right Arm Cuts/Bruise
Pain Level:
3
4
5
6
7
8
9
10
Type:
Aching
Sharp
Cramping
Radiating
Stiff
Spasm
Burning
Tight
Tingling
Freq:
Constant
Worse at night
Frequent
Worse in Afternoon
Worse in Morning
Which Activities Aggravate Your Condition?
Back Movement
Neck Movement
Sneezing
Bending
Reaching
Standing
Coughing
Sex
Using Restroom
Driving
Sitting
Walking
House Chores
Sleeping
Yard Work
Lifting
Other
Daily Habits:
0 = none 1 = a little 2 = moderate 3 = a lot
Smoking:
0
1
2
3
Alcohol:
0
1
2
3
Exercise:
0
1
2
3
Dominant Hand:
Left
Right
How long have you had this Condition?
Has this happened before?
Yes
No
How Often?
Was this due to a Trauma?
Yes
No
Details
Previous Traumas (Including minor car accident):
Previous Treatment:
Chiropractor
Primary Care
Physical Therapy
X-ray
CT Scan
Heat / Ice
Other
Medications:
Surgeries:
When was your last Chiropractic treatment?
What Technique?
Manual
Activator
Drop Table
Were you being treated for Wellness?
Yes
No
How frequently?
Primary Care Physician
Clinic Name:
Provider Name:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Please Select Any Recent Change in the Following Functions?
Absence of Smell
Fainting
Mouth Bleeding
Anxiety
Fatigue
Mouth Sores
Appetite Change
Forgetfulness
Nail Change
Blue Arms
Frequent Urination
Night Sweats
Blue Legs
Hair Change
Nose Bleeds
Change in Taste
Hearing Trouble
Nose Pain
Cold Intolerance
Heart Murmurs
Painful Urination
Concentration
Heat Intolerance
Palpitations
Convulsion
Impotence
Rash / Redness
Cough Wheezing
Inability to Urinate
Swollen Arms
Depression
Itching
Swollen Legs
Difficulty Breathing
Memory Loss
Tremors
Digestive Changes
Mood Swing
Weight Changes
Ear Pain
For Females:
Are you pregnant?
Not Sure
Yes
No
Breast Lump
Discharge of Breast
Vaginal Bleeding
Breast Pain
Irregular Menstruation
Vaginal Pain
Breast Red/Itching
Family Illness:
Father
Mother
Sibling
Illness?
Please Select Any of the Following Disorders that Apply to You:
Allergies
Hay Fever
Rheumatic Fever
Arthritis
Heart Disease
STD
Asthma
High Blood Pressure
Scoliosis
Bone Fracture
Kidney
Sinusitis
Cancer
Low Blood Pressure
Spinal Disc Disease
Diabetes
Multiple Sclerosis
Thyroid
Emotional Disorder
Polio
Tuberculosis
Epilepsy
Prostate
Ulcer
HIV
Signature:
Please verify that you are human
*
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