New Complaint Form

Dr. Aaron Rickelman, Dr. Abbi Rickelman, Dr. Brady Dougherty

1360 NW 18th Street, Suite 101, Ankeny IA 50023

Phone: 515.957.4042 Fax: 515.598.7855

New Complaint Form
Patient Name*
Today's Date*

MonthDayYear
Patient Email Address*
example@example.com
Please describe the symptom.*
On a scale of 0-10, with 10 being the worst, please select the number that best describes the symptom most of the time.*
While you are awake, what percentage of the time do you experience the symptom at the above intensity?*
Did the symptom begin:*

SuddenlyGraduallyOther
When did the symptom begin?*
How did the symptom begin?*
What makes the symptom worse? (Please indicate all that apply.)*

NothingAny MovementBending Neck ForwardBending Neck BackwardTilting Head RightTilting Head LeftTurning Head RightTurning Head LeftLaying on SideBending Forward at WaistBending Backward at WaistLeaning RightLeaning LeftSittingDrivingStandingWalkingRunningLiftingTransitional MovementChewingLying DownReadingWorkingExercisingOther
What makes the symptom better? (Please indicate all that apply.)*

Nothing So FarRestStandingWalkingSittingPain MedicationChiropractic CareMassageStretchingMovementOther
Describe the quality of the symptom. (Please indicate all that apply.)*

SharpDullAchyBurningTinglingThrobbingTight/StiffStabbingDeepNumbNaggingShootingStingingFleetingOther
Does the symptom radiate to another part of your body?*

YesNo
If yes, where does the symptom radiate?
Is the symptom worse at certain times of the day or night? (Please indicate all that apply.)*

No DifferenceMorningAfternoonEveningNightOther
Have you received treatment for the condition prior to today's visit? (Please indicate all that apply.)*

NoAnti-Inflammatory MedicationPain MedicationMuscle RelaxersTrigger Point InjectionsCortisone InjectionsSurgeryMassagePhysical TherapyChiropractic CareOther
What activities of daily living is this limiting?*

Should be Empty: