Dr. Katerina Captanis, DC
New Patient Form
ADULT QUESTIONNAIRE
CONFIDENTIAL PATIENT INFORMATION
TODAYS DATE
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Date
Name
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First Name
Last Name
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DATE OF BIRTH
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Year
Date
HEIGHT
WEIGHT
PATIENT CONTACT INFORMATION
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
CELL PHONE
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HOME PHONE
EMERGENCY CONTACT INFORMATION
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
HEALTH INFORMATION
THE SYMPTOM(S) THAT HAVE PROMPTED ME TO SEEK CARE TODAY INCLUDE:
AND ARE THE RESULT OF:
WHEN DID YOU FIRST NOTICE YOUR SYMPTOMS?
INTENSITY
Absent
1
2
3
4
5
6
7
8
9
Agonizing
10
1 is Absent, 10 is Agonizing
DURATION & TIMING
(WHEN DID IT START AND WHEN DO YOU FEEL IT?)
QUALITY OF SYMPTOMS
CHECK ALL THAT APPLY
NUMBNESS
TINGLING
STIFFNESS
DULL
ACHING
NAGGING
SHARP
BURNING
SHOOTING
STABBING
THROBBING
WHAT HAVE YOU DONE TO RELIEVE THE SYMPTOMS?
NOTHING
PRESCRIPTION MEDICATION
OVER-THE-COUNTER MEDS
PHYSICAL THERAPY
SURGERY
ICE/HEAT
MASSAGE
Other
What area(s) does the pain radiate, shoot, or travel to? (if applicable)?
What aggravates this complaint
Sitting
Standing
Walking
Getting up from seat
Walking stairs
Inactivity
Sleeping
Physical Activity
Exercise
Movement
Bending forward
Bending backward
Twisting
Reaching
Lifting
Desk work
Sneezing
Coughing
Everything
Unknown
Other
What relieves this complaint?
Sitting
Standing
Walking
Resting
Exercise
Movement
Stretching
Massage
Chiropractic
Heat
Ice
Laying down
Medication
Nothing
Unknown
Other
How often do you experience your symptoms?
25% of the day
50% of the day
75% of the day
100% of the day
Timing of complaint:
Morning
As day progresses
Afternoon
Evening
While sleeping
During activities
After activities
Symptoms are constant and do not change
Other
With time are your symptoms:
Improving
Worsening
Not changing
Have you seen other doctors for this complaint?
Yes
No
Please provide the following information
Doctor’s name:
Date consulted:
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Month
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Day
Year
Date
Diagnosis
Is this condition interfering with your:
Sleep
Getting in or out of bed or chair
Personal care
Travel
Work
Recreation
Lifting
Walking
Standing
Daily Routine
Social Activities
Exercise
Other
Is your complaint interfering with your daily activities?
Not at all
A little bit
Moderately
Quite a bit
Extremely
CURRENT MEDICATIONS
ANY ADDITIONAL INFORMATION OR HEALTH HISTORY
ACKNOWLEDGEMENTS: I instruct the chiropractor to deliver the care that, in his or her professional judgment, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern. I understand and am informed that, as in the practice of medicine and all healthcare, the practice of chiropractic carries some risks to treatment; including, but not limited to: fractures, disc injuries, strokes (CVA), dislocations, and sprains. I do not expect the physician to be able to anticipate and explain all risks and complications. Further, I wish to rely on the physician to exercise judgment during the course of the procedure which the physician feels are in my best interests at the time, based upon the facts then known. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its contents, and by signing below, I agree to the treatment recommended by my physician. I intend this consent form to cover the entire course of treatment for my present condition(s) and for any condition(s) for which I seek treatment at this facility.
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Patient Name
PATIENT SIGNATURE
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Date
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Day
Year
Date
DR. KATERINA CAPTANIS SIGNATURE
Date
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Date
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Appointment Deposit
A nonrefundable deposit will be required to book an appointment. 24 hours is required for cancellation or reschedule.
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