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 *

Month Day Year
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: *

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

Nothing Any Movement Bending Neck Forward Bending Neck Backward Tilting Head Right Tilting Head Left Turning Head Right Turning Head Left Laying on Side Bending Forward at Waist Bending Backward at Waist Leaning Right Leaning Left Sitting Driving Standing Walking Running Lifting Transitional Movement Chewing Lying Down Reading Working Exercising Other
What makes the symptom better? (Please indicate all that apply.) *

Nothing So Far Rest Standing Walking Sitting Pain Medication Chiropractic Care Massage Stretching Movement Other
Describe the quality of the symptom. (Please indicate all that apply.) *

Sharp Dull Achy Burning Tingling Throbbing Tight/Stiff Stabbing Deep Numb Nagging Shooting Stinging Fleeting Other
Does the symptom radiate to another part of your body? *

Yes No
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 Difference Morning Afternoon Evening Night Other
Have you received treatment for the condition prior to today's visit? (Please indicate all that apply.) *

No Anti-Inflammatory Medication Pain Medication Muscle Relaxers Trigger Point Injections Cortisone Injections Surgey Massage Physical Therapy Chiropractic Care Other
What activities of daily living is this limiting? *

Should be Empty: