New Patient Form

Dr. Katerina Captanis, DC
New Patient Form

ADULT QUESTIONNAIRE
CONFIDENTIAL PATIENT INFORMATION
TODAYS DATE*

MonthDayYear
Date
Name*

First NameLast Name
MFX
DATE OF BIRTH*

MonthDayYear
Date
HEIGHT
WEIGHT
PATIENT CONTACT INFORMATION
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
CELL PHONE
Please enter a valid phone number.
HOME PHONE
EMERGENCY CONTACT INFORMATION
Name

First NameLast 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

1

2

3

4

5

6

7

8

9

10

1 is Absent, 10 is Agonizing
DURATION & TIMING
(WHEN DID IT START AND WHEN DO YOU FEEL IT?)
QUALITY OF SYMPTOMS
NUMBNESSTINGLINGSTIFFNESSDULLACHINGNAGGINGSHARPBURNINGSHOOTINGSTABBINGTHROBBING
NOTHINGPRESCRIPTION MEDICATIONOVER-THE-COUNTER MEDSPHYSICAL THERAPYSURGERYICE/HEATMASSAGEOther
What area(s) does the pain radiate, shoot, or travel to? (if applicable)?
SittingStandingWalkingGetting up from seatWalking stairsInactivitySleepingPhysical ActivityExerciseMovementBending forwardBending backwardTwistingReachingLiftingDesk workSneezingCoughingEverythingUnknownOther
SittingStandingWalkingRestingExerciseMovementStretchingMassageChiropracticHeatIceLaying downMedicationNothingUnknownOther
25% of the day50% of the day75% of the day100% of the day
MorningAs day progressesAfternoonEveningWhile sleepingDuring activitiesAfter activitiesSymptoms are constant and do not changeOther
ImprovingWorseningNot changing
YesNo
Please provide the following information
Doctor’s name:
Date consulted:

MonthDayYear
Date
Diagnosis
SleepGetting in or out of bed or chairPersonal careTravelWorkRecreationLiftingWalkingStandingDaily RoutineSocial ActivitiesExerciseOther
Not at allA little bitModeratelyQuite a bitExtremely
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.*
Patient Name
PATIENT SIGNATURE*
Date*

MonthDayYear
Date
DR. KATERINA CAPTANIS SIGNATURE
Date

MonthDayYear
Date

My Products

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Dr. Katerina Captanis, DC

New Patient Form

CONFIDENTIAL PATIENT INFORMATION

PATIENT CONTACT INFORMATION

EMERGENCY CONTACT INFORMATION

HEALTH INFORMATION

QUALITY OF SYMPTOMS

Please provide the following information

Payment Methods