Chiropractic Patient Intake
Care Intake
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
Male
Female
Relationship Status
Married
Divorced
Separated
Single
Minor
Employer / School
Occupation
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who may we thank for referring you?
What brings you in today?
How bad is it on a scale of 1-10 (10 being the worst)?
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
What does it feel like? (check all that apply)
Numbness
Tingling
Stiffness
Dull
Aching
Cramping
Nagging
Sharp
Shooting
Burning
Throbbing
Stabbing
Swelling
IMPACT OF YOUR SYMPTOMS
How is this symptom/condition interfering with your life? (check where appropriate)
Work
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Exercise
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Recreation
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Relationships
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Sleep
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Self Care
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Energy
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Attitude
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Patience
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Productivity
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Creativity
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
How committed are you to correcting this issue?
Not Committed
1
2
3
4
5
6
7
8
9
Very Committed
10
1 is Not Committed, 10 is Very Committed
What number do you think represents your health today?
Disease
1
2
3
4
5
6
7
8
9
Optimal Health
10
1 is Disease, 10 is Optimal Health
In what direction is your health currently headed?
Towards Health
Towards Disease
IMMEDIATE
WHAT DO YOU WANT RIGHT NOW?
SHORT TERM
WHAT DO YOU WANT TO GET BACK TO?
LONG TERM
WHAT DO YOU WANT TO BE ABLE TO DO?
Please check the box beside any condition that you have or have had.
Alcoholism
Headaches/Migraines
PMS
Emotional Imbalance/Depression
Cancer
Abdominal bloating, cramps or gas
Irritable Bowel Syndrome
Ulcerative Colitis
Crohn's Disease and other intestinal disorders
Chronic Sinusitis
Asthma
Allergies
Diabetes Mellitus
Lupus
Rheumatoid Arthritis
Fibromyalgia
Chronic Fatigue
Hashimotos
Hypothyroidism
Hyperthyroidism
Autism
Autism
ADD/ADHD
Eczema
Skin Rashes
Hives
Gallbladder Disease
Kidney Disease
Stroke
Anemia
High Blood Pressure
High Cholesterol
Neuropathy/Nerve Problems
Gastric Bypass Surgery
Dialysis Treatment
Please check all that apply:
I am pregnant
I am breastfeeding
I may become pregnant in the near future
NA
Do you smoke or use tobacco products:
Yes
Ocassionally
Never
Do you drink alcohol or consume THC products:
>2x/week
<2x/week
Never
List all allergies (food and medication):
List all Medications and/or supplements you take:
Who is your primary doctor:
Do you give AHC permission to communicate directly with your physician in order to collaborate and coordinate your care?
Yes, I give permission to release known information and communicate with my doctor
No, AHC does not have my permission
Constipation and/or diarrhea
None
0
1
2
Severe
3
0 is None, 3 is Severe
Abdominal pain or bloating
None
0
1
2
Severe
3
0 is None, 3 is Severe
Mucous or blood in stool
None
0
1
2
Severe
3
0 is None, 3 is Severe
Joint pain or swelling, arthritis
None
0
1
2
Severe
3
0 is None, 3 is Severe
Chronic or frequent fatigue or tiredness
None
0
1
2
Severe
3
0 is None, 3 is Severe
Food allergies, sensitivities or intolerance
None
0
1
2
Severe
3
0 is None, 3 is Severe
Sinus or nasal congestion
None
0
1
2
Severe
3
0 is None, 3 is Severe
Chronic or frequent inflammations
None
0
1
2
Severe
3
0 is None, 3 is Severe
Eczema, skin rashes or hives
None
0
1
2
Severe
3
0 is None, 3 is Severe
Asthma, Hay fever, or airborne allergies
None
0
1
2
Severe
3
0 is None, 3 is Severe
Confusion, poor memory or mood swings
None
0
1
2
Severe
3
0 is None, 3 is Severe
Use of NSAIDS (Aspirin, Tylenol, Motrin)
None
0
1
2
Severe
3
0 is None, 3 is Severe
History of antibiotic use
None
0
1
2
Severe
3
0 is None, 3 is Severe
Alcohol consumption makes you feel sick
None
0
1
2
Severe
3
0 is None, 3 is Severe
Gluten sensitivity or Celiac's disease
None
0
1
2
Severe
3
0 is None, 3 is Severe
Nausea
None
0
1
2
Severe
3
0 is None, 3 is Severe
Weight issues
None
0
1
2
Severe
3
0 is None, 3 is Severe
Submit
Should be Empty: