Physis Chiropractic Intake Form

Physis Chiropractic Intake Form

Please complete this form prior to your Initial Exam Appointment
Are you filling this out for:*
Patient Information
Name*

PrefixFirst NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Gender
Phone Number*
Email*
example@example.com
Occupation
Who may we thank for referring you?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Phone Number*
Relationship
Mom or Dad's Name

First NameLast Name
Medical Doctor's Name

First NameLast Name
Practice Name
Phone Number
History of Primary Complaint

Tell us what brings you into the office:
Purpose of visit or complaint*
Note the location and symptoms of primary complaint
Have you had previous episodes of this complaint?

YesNo
Frequency:*

Constant (100%)Frequent (>75%)Off & On (>50%)
When did you start experiencing this problem?*

MonthDayYear
Date
Does it radiate?*

NoYes (where?)
In scale of 1-10, what is the intensity or severity of the complaint? *

1

2

3

4

5

6

7

8

9

10

1 is Best, 10 is Worst
What type of pain are you experiencing?*

NumbnessSharp painTinglingBurningDull painStiffness
Improves with:*

Ice/HeatRestMovement/StretchingOTC MedicationsOther
Worsens with:*

SittingStanding/WalkingLying down/SleepingOveruse/LiftingOther
Previous Treatment:*

NoneChiropractorMedical Doctor/DOPhysical TherapyER/Urgent CareOrthopedicOther
Previous Diagnostic Testing:*

NoneX-RaysMRICTOther
Past, Family, and Social History

Tell us about your health history and lifestyle factors:
Has anyone in your immediate family received any of the following diagnoses?*

NoneHeart DiseaseHigh Blood PressureDiabeter MellitusCancerArthritisStrokeUnknown
Were you previously hospitalized? If yes, please indicate when and why:
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:
Have you ever had any of the following conditions? (If no, select NONE)*

HypertensionHeart issuesRashesDiabetes MellitusBone problemsBlood ClottingSpams/CrampsIrregular Menstrual CycleSprainsVaricose VeinsConstipationArthritisSeizureSpinal Cord IssuesInfertilityChronic coughAsthmaFrequent HeadachesNausea/VomitingDizziness/VertigoEars Ringing/TinnitisNeck painBack painHips painLegs painTremorsInfectious diseasesVision problemTrouble focusingLow energyBrain FogNervousness/AnxietyDepressionKidneyIncontinenceRecent unexpected weight changeIrregular Bowel MovementsConstipationNone
Do you have any Drug or Food Allergies? If yes, please list below
Are you pregnant, breastfeed, or nursing? (Female)*

YesNoN/A
How often do you exercise?

Daily4-5x/wk2-3x/wkRarelyNever
What type of exercises you do?

StrenuousModerateLightNone
Do you smoke? If yes, how many packs a day?
Alcohol Use:

DailyWeeklyOccasionallyNever
Do you wear any implantable medical devices? If yes, what are these devices?
Are you currently taking any medications? If yes, please list them below:
Are you currently taking any nutritional supplements? If yes, please list them below:
How Can We Help Your Child?
Reason for Visit*

Wellness CheckupSleepDigestiveConnectionOther (Please Describe)
Has your child been treated on an emergency basis?*

YesNo
Pregnancy History
Did you experience any complications during your pregnancy (Select all that apply)*

Back/Other PainPre-TermGestational DiabetesFatiguePre/EclampsiaSwellingStrep BNausea/VomittingOther (Please Describe)
Birth History
Type of Birth (Check all that apply):*

HospitalBirth CenterHomeNormal/VaginalBreechCesareanScheduled/InducedEpidural
Problems during Labor/Delivery?*

AntibioticsCongenital AnomaliesFailure to ThriveJaundiceMeconiumRespiratory DistressExtended HospitalizationOther (please specify)
Growth & Development
Infant Feeding:*

BreastBottleFormula
Number of hours of sleep each night:*
Quality of sleep:*
At what age did the child first respond to sound?*
At what age did the child first crawl?*
At what age did the child first hold their head up?*
At what age did the child first stand?*
At what age did the child first walk unsupported?*
Childhood Diseases, Illnesses, Vaccinations
Has your child had (mark all that apply):*

Chicken PoxMumpsMeaslesRubellaRubeolaPertussis/Whooping Cough
Has your child ever suffered from (mark all that apply):*

AllergiesAnemiaArm ProblemsAsthmaBack AchesBed WettingBehavioral ProblemsBroken BonesChronic Ear AchesColds/FluColicConvulsions/SeizuresDelayed SpeechDiabetesDigestive Issues (Constipation/Diarrhea)DizzinessFaintingHeadachesHeart TroubleHyperactivityHypertensionJuvenile Rheumatoid ArthritisJoint ProblemsLeg ProblemsNeck ProblemsNeuritisOrthopedic ProblemsParalysisPoor AppetiteRuptures/HerniasSinus TroubleTuberculosisWalking ProblemsOther
Have you Vaccinated your child?
Allergies, Medications, Surgeries & Family History
Allergies (list)*
Medications (list)*
Surgeries (list)*
Family History (list)*
Siblings
How many children do you have?
Number of pregnancies
Children's Ages:
Children's Health Concerns:
Are you currently pregnant?*

YesNo
Health Concerns regarding this pregnancy?
Authorization and Consent
- I confirm that all information given in this form is true, complete, and accurate.
- I released this organization for any responsibility in case of accident, illness, or injury.
- I acknowledge that no assurance was offered about the outcome.
- I acknowledge that I received an Informed Consent document and the health staff explained it to me thoroughly.
- HIPAA: I confirmed that I have read and received the HIPAA Privacy Practices of this chiropractor's office regarding protected health information
Signature of the Patient*

Clear
Should be Empty:

Physis Chiropractic Intake Form

Patient Information

History of Primary Complaint

Past, Family, and Social History

How Can We Help Your Child?

Pregnancy History

Birth History

Growth & Development

Childhood Diseases, Illnesses, Vaccinations

Allergies, Medications, Surgeries & Family History

Siblings

Authorization and Consent