kirklandchiropractor.org - New Patient Intake Form

New Patient Intake Form
Patient Name:

First NameMiddle NameLast Name
Date:

MonthDayYear
Date
MaleFemaleOther
Date of Birth:

MonthDayYear
Date
Social security number:
Address:
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
HomeCell
Preferred Language:
HispanicNon-HispanicUnknown (A person who cannot or does not want to declare ethnicity).
BlackWhiteNative American/Eskimo/AleutAsian/Pacific IslanderUnknownOther
Employer:
Occupation:
Emergency Contact:
Name:
Cell:
Please enter a valid phone number.Format: (000) 000-0000.
Home:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Primary Health Care provider:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Health History:
YesNo
What medications are you currently taking? Please include supplements, herbal remedies, and over the counter medications.
Please list other medications you have taken over the last 3 months:
List all allergies (including food and environmental):

Do you smoke?

Please mark the body front and back with the appropriate letters from the chart listed below.

CP – Constant pain	P – Pain
S – Swelling	T – Tenderness
N – Numbness	Tg – Tingling
R – Redness	E – Effusion (puffiness or edema)
L - Limitation	W - Weakness

Please indicate on the diagram where your major symptoms are:
How long have you had these symptoms? (Itemize the different body areas if appropriate):

Activities of Daily Living Questionnaire
Work:
What type of work do you do?
How many hours per day are you able to work now?
Prior to Injury?
Days per week now?
How is your work affected or lost by your injury?
Home/Family:
List the activities affected by your injury?
Sleep:
How many hours per night do you sleep now?
Prior to injury?
Do you feel rested now?
Prior to injury?
What affects your sleep? (Examples- pain, not able to go to sleep, not able to wake up etc.)
Social/Recreational:
Activities:
Prior to injury?
How are your current activities affected?
Name:
Date:

MonthDayYear
Date
Signature:

Clear

New Patient Intake Form