PATIENT INTAKE FORM
Patient Name:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1. Is today's problem caused by:
Auto Accident
Workman's Compensation
2. Indicate on the drawings below where you have pain/symptoms
3. How often do you experience your symptoms?
Constantly (76-100% of the time)
Occasionally (26-50% of the time)
Frequently (51-75% of the time)
Intermittently (1-25% of the time)
4. How would you describe the type of pain?
Sharp
Numb
Dull
Tingly
Diffuse
Sharp with motion
Achy
Shooting with motion
Burning
Stabbing with motion
Shooting
Electric like with motion
Stiff
Other
5. How are your symptoms changing with time?
Getting Worse
Staying the Same
Getting Better
6. Using a scale from 0-10 (10 being the worst), how would you rate your problem?
No Pain
1
2
3
4
5
6
7
8
9
Worst Pain
10
1 is No Pain, 10 is Worst Pain
7. How much has the problem interfered with your work?
Not at all
A little bit
Moderately
Quite a bit
Extremely
8. How much has the problem interfered with your social activities?
Not at all
A little bit
Moderately
Quite a bit
Extremely
9. Who else have you seen for your problem?
Chiropractor
Neurologist
Primary Care Physician
ER physician
Orthopedist
Massage Therapist
Physical Therapist
No one
Other
10. How long have you had this problem?
11. How do you think your problem began?
12. Do you consider this problem to be severe?
Yes
Yes, at times
No
13. What aggravates your problem?
14. What concerns you the most about your problem; what does it prevent you from doing?
15. What is your:
Height
Weight
Age
Occupation
16. How would you rate your overall Health?
Excellent
Very Good
Good
Fair
Poor
17. What type of exercise do you do?
Strenuous
Moderate
Light
None
18. Indicate if you have any immediate family members with any of the following:
Rheumatoid Arthritis
Diabetes
Lupus
Heart Problems
Cancer
ALS
19. For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column
Rows
Past
Present
Headaches
High Blood Pressure
Diabetes
Neck Pain
Heart Attack
Excessive Thirst
Upper Back Pain
Chest Pains
Frequent Urination
Mid Back Pain
Stroke
Smoking/Tobacco Use
Low Back Pain
Angina
Drug/Alcohol Dependance
Shoulder Pain
Kidney Stones
Allergies
Elbow/Upper Arm Pain
Kidney Disorders
Depression
Wrist Pain
Bladder Infection
Systemic Lupus
Hand Pain
Painful Urination
Epilepsy
Hip Pain
Loss of Bladder Control
Dermatitis/Eczema/Rash
Upper Leg Pain
Prostate Problems
HIV/AIDS
Knee Pain
Abnormal Weight Gain/Loss
Ankle/Foot Pain
Loss of Appetite
Jaw Pain
Abdominal Pain
Joint Pain/Stiffness
Ulcer
Arthritis
Hepatitis
Rheumatoid Arthritis
Liver/Gall Bladder Disorder
Cancer
General Fatigue
Tumor
Muscular Incoordination
Asthma
Visual Disturbances
Chronic Sinusitis
Dizziness
Other:
For Females Only
Rows
Past
Present
Birth Control Pills
Hormonal Replacement
Pregnancy
20. List all prescription medications you are currently taking:
21. List all of the over-the-counter medications you are currently taking:
22. List all surgical procedures you have had:
23. What activities do you do at work?
Sit:
Most of the day
Half the day
A little of the day
Stand:
Most of the day
Half the day
A little of the day
Computer work:
Most of the day
Half the day
A little of the day
On the phone:
Most of the day
Half the day
A little of the day
24. What activities do you do outside of work?
25. Have you ever been hospitalized?
Yes
No
If yes, why
26. Have you had significant past trauma?
Yes
No
27. Anything else pertinent to your visit today?
Patient Signature
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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