Neuropathy Intake

Neuropathy Intake

Female
About You
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth Date: *
Birth Gender:

MaleFemale
Height:
Weight:
Occupation:
Marital Status:

SingleMarriedSeparatedDivorced
Spouse's Name:
How did you hear about us? *
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation to you?
HIPPA Release
This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization. I give Eastern Iowa Health and Wellness Center/Family and Sport Chiropractic/Iowa Wellness Center permission to disclose medical information concerning:

AppointmentsMedical InformationBoth
This information can be released to the following people: (please include names and phone numbers)
Signature
I authorize Eastern Iowa Health and Wellness Center/Family and Sport Chiropractic to send updates on my treatment/condition to my primary care physician.

YesNo
Primary Care Physician Name:

First NameLast Name
PCP Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When were you last seen there?
History
Please select the following that pertain to your present health / past medical history:*

AnemiaAsthmaArthritisAllergies/SensitivitiesArtificial JointAtherosclerosisBruise EasilyCancerCarpal Tunnel SyndromeContagious Skin ConditionMononucleosisFrequent Colds & FluDeep Vein Thrombosis/Blood ClotsDiabetesEpilepsyHeadaches/MigrainesHeart ConditionMumpsRheumatoid ArthritisOpen Sores/WoundsNervous DisordersPhlebitisShortness of BreathPregnancyHigh/Low Blood PressureHepatitisFractureHigh CholesterolKidney DiseaseSwollen GlandsSprains/StrainsThyroid ProblemsSyphilisTuberculosisGonorrheaHigh FeversPneumoniaStrokeJaundiceMental IllnessAlcoholismTennis ElbowTMJRheumatic FeverVein ProblemsChicken PoxPolioNervous DisordersHIVSkin RashesInsomniaMultiple SclerosisObesityMeningitisOsteoporosisFibromyalgiaBronchitisNone of the aboveOther
If other is checked, please explain:
If diabetes is checked above, how many years?
Are you a smoker? If yes, what is the frequency?
Do you consume alcohol? If yes, what is the frequency?
Do you consume caffeine? If yes, what is the frequency?
Do you have a pacemaker or defibrillator?
Please check any of the following that have occured in your family (blood relative):*

Heart DiseaseDiabetesOsteoporosisAlzheimer's DiseaseCancerHigh Blood PressureAllergiesAlcoholismAnemiaAsthmaBleeding TendenciesKidney DiseaseMental IllnessObesityStrokeThyroid ProblemsTuberculosisOtherNone apply
If other is checked, please explain:
Please list any Disease/Illnesses/Surgeries below with dates:
Please list any Allergies and Reactions below or reply none: *
Please shade in any areas corresponding to any problem area(s):*
Ex: 10, 21, 50
Women's Health
Are you pregnant?*

YesNo
Are you nursing?*

YesNo
Are you taking birth control?*

YesNo
Do you experience painful periods?*

YesNo
Do you have irregular cycles?*

YesNo
Do you have breast implants?*

YesNo
Do you perform a regular self-breast examination?*

YesNo
Do you take hormone replacement therapy (HRT)?*

YesNo
Do you take oral contraceptives?*

YesNo
When was your last PAP/pelvic exam?*

Within the past yearBetween 1-4 yearsGreater than 5 yearsNever had a PAP or pelvic examPrefer not to answer or don't know
What was the date of your last menstrual period? (only answer if still menstruating)*

Within the past month or currentlyWithin the past 1-3 monthsGreater than 3 monthsPostmenopausalHave not yet begun menstruationPrefer not to answer or don't know
Quality of Life
Has your condition affected your sleep?*

YesNo
If yes, how?
Is there a certain time of day any of these problems are better or worse? *
Is your balance/walking ability affected?*

YesNo
If yes, how?
Have you had any procedures/surgeries specific to your Neuropathy?*

YesNo
If yes, what?
Are you currently or have you received any of the following?*

GabapentinPain MedicationsNeurontinInjectionsLyricaSurgeriesCymbaltaNone of the above
How have you taken care of your health in the past?*

MedicationsEmergency RoomRoutine MedicalExerciseNutrition/DietHolistic CareVitaminsChiropracticNone of the aboveOther
If other, please explain:
How did the previous method(s) work out for you?*

Bad resultsSome resultsGreat resultsNothing changedDid not get worseDid not work very longStill tryingConfusedNone of the above
How have others been affected by your health condition?*

No one is affectedHaven't noticed any problemsThey tell me to do somethingPeople avoid me
What are you afraid this might be (or beginning) to affect (or will affect)?*

JobKidsFuture abilityMarriageSelf-esteemSleepTimeFinancesFreedomNone of the above
Are there health conditions you are afraid this might turn into?*

Family health problemsHeart diseaseCancerDiabetesArthritisFibromyalgiaDepressionChronic FatigueNeed surgeryNone of the above
How has your health condition affected your job, relationships, finances, family, or other activites? Please give examples:*
What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) Give 3 examples:*
What are you most concerned with regarding your problem? *
Where do you see yourself being in the next 1-3 years if this problem is not taken care of? Please be specific:*
What would be different/better without this problem? Please be specific: *
What do you desire most to get from working with us? *
What would that mean to you? *
Other Symptoms
Fatigue:*

NeverMildModerateSevere
Mood Changes (irritability, anxiety/nervousness, depression):*

NeverMildModerateSevere
Decreased Mental Ability (memory loss, confusion, loss of focus):*

NeverMildModerateSevere
Hot Flashes/Night Sweats:*

NeverMildModerateSevere
Weight Gain (bloating, excessive belly fat, inability to lose weight):*

NeverMildModerateSevere
Decreased Sex Drive (vaginal dryness):*

NeverMildModerateSevere
Sleep Problems (can't stay asleep, can't fall asleep):*

NeverMildModerateSevere
Cold Hands & Feet / Always Cold:*

NeverMildModerateSevere
Hair Loss / Breakage:*

NeverMildModerateSevere
Dry Wrinkled Skin:*

NeverMildModerateSevere
What are you interested in getting help with?*

Acne/RosaceaAesthtics (skin care)Anti-AgingBio-Identical HormonesBody SculptingBotoxCellulite ReductionDiastasis RectiDetoxificationEmsculpt NeoFood SensitivitiesHair RegenerationHelp with SleepLaser Hair RemovalLaser Tattoo RemovalLaser Nail Fungus RemovalLight TherapyWeight Loss/Weight ManagementMicro-NeedlingNutritionPain ManagementSexual EnhancementSkin TighteningStem CellsWrinkle ReductionUrinary IncontinenceLeaking of UrineFrequent UrinationNone of the above
Please bring an up to date medication list with you to your appointment. Do not bring your actual medications to the clinic, just a list please.
Should be Empty: