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Wexford, PA
Monroeville, PA
Washington, PA
Boardman, OH
Altoona, PA
Weirton, WV
Morgantown, WV
Name
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First Name
Last Name
Birth Date
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Month
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Day
Year
Date
Gender
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Female
Male
Email
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example@example.com
Phone Number
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Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security
Your Occupation
Retired?
Yes
No
Spouse's Name
First Name
Last Name
How did you hear about us?
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REVIEW OF SYMPTOMS
Please check all that apply
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Foot Pain
Hand Pain
Low Back Pain
Neck Pain
Foot Numbness
Hand Numbness
Diabetes
High Cholesterol
High Blood Pressure
Pacemaker/Defibrillator
Herniated Disc
Bulging Disc
Spinal Stenosis
Degenerative Disc
Vascular Problems
Leg Pain
Plantar Fasciitis
Morton's Neuroma
Cancer
Chemotherapy
Arthritis in Hands
Arthritis in Feet
Sciatica
Pinched Nerve
Poor Circulation
Joint Replacement
Foot Surgery
Poor Wound Healing
Excessive Thirst or Urination
Implanted Cord/Bladder Stimulator
PRESENT HEALTH CONDITION
In order of importance, list the health problems you are most interested in getting corrected: (click the + button to add more)
List approximately how long you have noticed these problems: (click the + button to add more)
Is there a certain time of day any of these problems are better or worse?
Check the things you have used for these problems:
Gabapentin
Neurontin
Lyrica
Cymbalta
Physical Therapy
Pain Medications
Aleve
Tylenol
Ibuprofen
Motrin
Chiropractic
Massage Therapy
Injections
Creams
Other
Is your balance/walking ability affected?
Yes
No
If yes, please describe:
What do you think is causing your problem?
List all of the doctors you have seen for these problems and treatment you received: (click the + button to add more)
Have your symptoms:
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Improved
Worsened
Stayed the same
List anything that makes your condition worse: (click the + button to add more)
List anything that makes your condition better: (click the + button to add more)
How would you describe the symptoms? Please check all that apply
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Aching Pain
Stabbing Pain
Sharp Pain
Tiredness
Numbness
Tingling
Pins & Needles Pain
Heavy Feeling
Hot Sensation
Throbbing Pain
Dead Feeling
Cold Hands/Feet
Cramping
Swelling
Burning
Electric Shocks
None
Other
Is this condition interfering with any of the following?
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Sleep
Work
Walking
Standing
Daily Activities
Recreational Activities
None
Other
List all allergies/sensitivities to medication, food and other items here: (click the + button to add more)
List all prescription drugs you are currently taking and dosage of each: (click the + button to add more)
List all nutritional supplements (vitamins, herbs, homeopathics, etc) you are currently taking and dosage of each: (click the + button to add more)
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SOCIAL HISTORY
Do you smoke?
Yes
No
If yes, how many cigarettes daily?
Do you drink?
Yes
No
If yes, how many drinks per week?
Do you exercise regularly?
Yes
No
If yes, please describe type & how often:
CURRENT PAIN LEVELS
With 1 being "No Pain" and 10 being the "Worst Pain Possible"; How would you rate your pain in the last week
With 1 being "No Pain" and 10 being the "Worst Pain Possible"; If you had to accept some level of pain after completion of treatment, what would be an acceptable level?
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PATIENT QUALITY OF LIFE SURVEY
How have you taken care of your health in the past?
Medications
Emergency Room
Routine Medical
Exercise
Nutrition/Diet
Holistic Care
Vitamins
Chiropractic
Other
How did the previous method(s) work out for you?
Bad results
Some results
Great results
Nothing changed
Did not get worse
Did not work very long
Still trying
Confused
How have others been affected by your health condition?
No one is affected
Haven't noticed any problem
They tell me to do something
People avoid me
What are you afraid this might be (or beginning) to affect (or will affect)?
Job
Kids
Future ability
Marriage
Self-esteem
Sleep
Time
Finances
Freedom
Are there health conditions you are afraid this might turn into?
Family health problems
Heart disease
Cancer
Diabetes
Arthritis
Fibromyalgia
Depression
Chronic Fatigue
Need Surgery
How has your health condition affected your job, relationships, finances, family or other activities? Please give examples:
What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) Give 3 examples:
What are you most concerned with regarding your problem?
Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specific
What would be different/better without this problem? Please be specific
What do you desire most to get from working with us?
What would that mean to you?
Please verify that you are human
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