kirklandchiropractor.org - Returning Patient Intake Form

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:

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Re-Exam Packet