Schrier Family Chiropractic and Regenerative Medicine Intake Form

Patient Information
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState/Territory

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Phone Number*
E-mail*
Occupation
Medications
Allergies
How did you hear about us?

GoogleFamily/Friend ReferralAnother Health PractitionerFacebookOther
History of Symptoms
1. List Areas of Discomfort or Pain
2. Describe Onset of Discomfort or Pain
3. Rate of Pain Today
4. Frequency - please select the most accurate

ConstantOff/OnAt RestWith ActivityOther
5. At what time of day is the pain at its worse?

MorningAfternoonEveningDuring SleepOther
6. Have you ever injured this area before?
7. Have you ever been in an accident (automobile, work, falls, etc.) ?
8. List all related treatments received for this injury.
9. Have you ever treatment for this specific problem or injury? If yes, what type?
Was the treatment used effective?
10. Are you currently seeing any other healthcare professional?
11. Is there anything that you do that creates, increases or decreases pain?
12. What are the physical duties required of your occupation?
13. What activities/hobbies do you enjoy?
14. Please list exercise and stress reduction activities (including frequency).
15. In what position do you most often wake up?

BackSideStomachOther
Please Check Any of The Following You Would Like More Info About

Decompression Disc TherapyHormone Replacement Therapy(HRT)IV VitaminsMassageFloatation TherapyKnee Regeneration TherapyShoulder Regeneration TherapyNeuropathy TherapyAllergy TestingAesthetics(Botox, Fillers, PRP facials)AcupunctureMedical Weight LossMigraine Therapy
Head

TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsVertigoMigrainesHeadachesLow EnergyBrainfogMemory ProblemsOther
Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationSharp painOther
Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headCan't sleep on shoulderOther
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strengthOther
Mid-Back

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low Back

Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther
Hip

Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Leg, Knees and Feet

Pain down RIGHT legPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
HEALTH HISTORY PAST AND PRESENT

AlcoholismAllergyAnaemiaArthritisAsthmaBack PainBursitisCancerConstipationCrampsChest PainDepressionDiabetesDiahorreaEczemaEpilepsyGall BladderGoutHeadachesHeart DiseaseHeart AttackHigh BPHIV (Aids)Irregular PeriodsLow BPPeriod PainMigranesMiscarriageMSNervousnessNeuritisRinging in EarsSinus ProblemsStrokeThyroid IssuesTurberculosisUlcersOther
Family Medical History(If any symptoms run in your family )

AllergiesArthritisBursitisCancerDepressionDiabetesDigestive DisorderFatigue Low EnergyFibromyalgiaHigh Blood PressureHeadachesHigh CholesterolKnee PainLow Back PainNeck PainNumbness/TinglingOsteoporosisSciaticaTMJDisc HerniationsOther
I attest that all the information above is true: Signature

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