Chiropractic Update Form
Patient Information
Name
*
Mr.
Mrs.
Dr.
Ms.
Miss.
Prefix
First Name
Middle Name
Last Name
Suffix
Today's Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Doctor's Name
First Name
Last Name
Phone Number
Hospital Name
Emergency Contact Information
Name and number of who you would like us to contact in case of emergency
Description of Accident, Injury, or Onset of Pain
Please enter a full description of what is bringing you to see Dr. Kirshner today in the space below.
*
Description of Symptoms
Please type your primary complaint in the box below. Ex: Low back, Mid back, Upper back, Neck, Shoulder, etc.
*
When did you start experiencing this problem?
*
-
Month
-
Day
Year
Date
On a scale of 1-10, how much pain is this symptom currently causing you?
*
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
What type of pain are you experiencing?
*
Dull
Aching
Sharp
Stiffness
Numbness
Tingling
Shooting
Constricting
Stinging
Other
How often does it bother you during the day?
*
Under 25% of the day
25%-50% of the day
50%-75% of the day
All day long
Other
When is the pain the worst?
*
Morning
Bedtime
Afternoon
Evening
All day long
Only after activity
Other
If you have a second symptom, add here [if not, skip down to relief box]:
When did you start experiencing this problem?
-
Month
-
Day
Year
Date
On a scale of 1-10, how much pain is this symptom currently causing you?
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
What type of pain are you experiencing?
Dull
Aching
Sharp
Stiffness
Numbness
Tingling
Shooting
Constricting
Stinging
Other
How often does it bother you during the day?
Under 25% of the day
25%-50% of the day
50%-75% of the day
All day long
Other
When is the pain the worst?
Morning
Bedtime
Afternoon
Evening
All day long
Only after activity
If you have a third symptom, add here:
When did you start experiencing this problem?
-
Month
-
Day
Year
Date
On a scale of 1-10, how much pain is this symptom currently causing you?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What type of pain are you experiencing?
Dull
Aching
Sharp
Stiffness
Numbness
Tingling
Shooting
Constricting
Stinging
How often does it bother you during the day?
Under 25% of the day
25%-50% of the day
50%-75% of the day
All day long
When is the pain the worst?
Morning
Bedtime
Afternoon
Evening
All day long
Only after activity
If you have a fourth symptom, add here:
When did you start experiencing this problem?
-
Month
-
Day
Year
Date
On a scale of 1-10, how much pain is this symptom currently causing you?
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
What type of pain are you experiencing?
Dull
Aching
Sharp
Stiffness
Numbness
Tingling
Shooting
Constricting
Stinging
Other
How often does it bother you during the day?
Under 25% of the day
25%-50% of the day
50%-75% of the day
All day long
Other
When is the pain the worst?
Morning
Bedtime
Afternoon
Evening
All day long
Only after activity
What have you tried so far for relief? Ex: ice, heat, physical therapy, stretching, over-the-counter pain relievers, etc.
*
Height
*
Weight
On a scale of 1-5, how much difficulty do you have with Self Care Activities? This includes: bathing, brushing teeth, getting dressed, eating, laundry, and dishes.
*
No Difficulty
1
2
3
4
Cannot Complete
5
1 is No Difficulty, 5 is Cannot Complete
On a scale of 1-5, how much difficulty do you have with Physical Activity? This includes: standing, walking, sitting, bending, twisting, and turning.
*
No Difficulty
1
2
3
4
Cannot Complete
5
1 is No Difficulty, 5 is Cannot Complete
On a scale of 1-5, how much difficulty do you have with Functional Activity? This includes carrying objects, lifting weights, climbing stairs, and exercising.
*
No Difficulty
1
2
3
4
Cannot Complete
5
1 is No Difficulty, 5 is Cannot Complete
On a scale of 1-5, how much difficulty do you have with Recreational Activity? This includes bowling, golfing, jogging, dancing, swimming, skating, and dining out.
*
No Difficulty
1
2
3
4
Cannot Complete
5
1 is No Difficulty, 5 is Cannot Complete
On a scale of 1-5, how much difficulty do you have with Communication? This includes concentrating, hearing, speaking, reading, and writing.
*
No Difficulty
1
2
3
4
Severe Difficulty
5
1 is No Difficulty, 5 is Severe Difficulty
On a scale of 1-5, how much difficulty do you have with using your Senses? This includes seeing, hearing, touch, taste, and smell.
*
No Difficulty
1
2
3
4
Severe Difficulty
5
1 is No Difficulty, 5 is Severe Difficulty
On a scale of 1-5, how much difficulty do you have with sleeping.
*
No Difficulty
1
2
3
4
Severe Difficulty
5
1 is No Difficulty, 5 is Severe Difficulty
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