trumotion.org - Adult Patient Questionnaire Pack Form

Adult Patient Questionnaire Pack Form
Confidential Patient Information
Name

First NameLast Name
Date

MonthDayYear
Date
SSN
Date of Birth

MonthDayYear
Date
Sex
Occupation
# of Children
Marital Status

SingleMarriedDivorcedSeparatedWidowed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Height
Weight
Email address
example@example.com
Mobile phone number
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Emergency Contact
Emergency Relation
Emergency Phone Number
Please enter a valid phone number.
How did you hear about us?
Who is your primary care physician?
Date and reason for your last visit doctor?
Are you receiving care from any other health professionals?

YesNo
If yes, please name them and their specialty
Please note any significant family medical history?
Current Health Conditions
What health condition(s) bring you into our office?
Please describe where you are experiencing pain or discomfort

Right shoulderLeft shoulderRight armLeft armRight hipLeft hipRight kneeLeft kneeRight ankleLeft ankleNapeRight shoulder bladderLeft shoulder bladderUpper backMiddle backLow backRight elbowLeft elbow
Please describes where you experienced pain or discomfort

Right shoulderLeft shoulderRight armLeft armRight hipLeft hipRight kneeLeft kneeRight ankleLeft ankleNapeRight shoulder bladderLeft shoulder bladderUpper backMiddle backLow backRight elbowLeft elbow
Have you received care for this problem before?

YesNo
If yes, please explain
When did the condition(s) first begin?
How did the problem start?

SuddenlyGraduallyPost Injury
In this condition:

Getting worseImprovingIntermittentConstantUnsure
What makes the problem better?
What makes the problem worse?
Your Health Goals
What are your top three health goals?
Chiropractic History
What would you like to gain from chiropractic care?

Resolving existing condition(s)Overall wellnessBoth
Have you ever visited a chiropractor?

YesNo
If yes, what is their name?
What is their specialty?

Pain ReliefPhysical Therapy & RehabNutritionSubluxation-basedOther
Do you have any health concerns for other family members today?
TRAUMAS: Physical Injury History
Have you ever had any significant falls, surgeries or other injuries as an adult?

YesNo
If yes, please explain
Notable childhood injuries?

YesNo
If yes, please explain
Youth or college sports?

YesNo
If yes, list major injuries
Any past auto accidents?

YesNo
If yes, please explain
How often do you exercise?

None1-3x per week4-6x per weekDaily
What types of exercise?
How do you normally sleep?

BackSideStomach
Do you wake up?

Refreshed and readyStiffed and tired
Do you commute to work?

YesNo
If yes, how many minutes per day?
List any problems with flexibility
Ex: putting on shoes/socks,...
How many hours per day do you typically spend sitting at a desk?
On a computer, tablet or phone?
TOXINS: Chemicals & Environmental Expose

Please rate your CONSUMPTION for each:
Alcohol

1

2

3

4

5

1 is None, 5 is High
Water

1

2

3

4

5

1 is None, 5 is High
Sugar

1

2

3

4

5

1 is None, 5 is High
Dairy

1

2

3

4

5

1 is None, 5 is High
Gluten

1

2

3

4

5

1 is None, 5 is High
Processed Foods

1

2

3

4

5

1 is None, 5 is High
Artificial Sweeteners

1

2

3

4

5

1 is None, 5 is High
Sugary Drinks

1

2

3

4

5

1 is None, 5 is High
Cigarettes

1

2

3

4

5

1 is None, 5 is High
Recreational Drugs

1

2

3

4

5

1 is None, 5 is High
Please list any drugs/ medications/ vitamins/ herbs or other that you are taking and why?
THOUGHTS: Emotional Stresses & Challenges

Please rate your STRESS for each:
Home

1

2

3

4

5

1 is None, 5 is High
Work

1

2

3

4

5

1 is None, 5 is High
Life

1

2

3

4

5

1 is None, 5 is High
Money

1

2

3

4

5

1 is None, 5 is High
Health

1

2

3

4

5

1 is None, 5 is High
Family

1

2

3

4

5

1 is None, 5 is High
Acknowledgement & Consent
Patient Signature

Clear
Date

MonthDayYear
Date
Patient Review of Systems
REGION: CERVICAL

Functions:
- Autonomic Nervous System
- ENT System
- Vision, Balance & Coordination
- Speech
- Immune System
- Digestive System
- Nerve Supply to Shoulders, Arms & Hands
- Sympathetic Nucleus
- Metabolism
PLEASE SELECT THE SYMPTOMS YOU EXPERIENCED.

Colic & Excessive CryingEar & Sinus InfectionsAllergies & CongestionImmune DeficiencyHeadache & MigrainesVertigo & DizzinessSore Throat & StrepSwollen Tonsils & AdenoidsVison & Hearing IssuesLow Energy & FatigueDifficulty SleepingPain, Numbness & Tingling in Arms to HandsEpilepsy & SeizuresSensory & SpectrumADD / ADHDFocus & Memory IssuesAnxiety & StressBalance & CoordinationSpeech IssuesTMJ / Jaw PainStiff Neck & ShouldersDepressionHigh Blood PressurePoor Metabolism & Weight Control
PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING

Colic & Excessive CryingEar & Sinus InfectionsAllergies & CongestionImmune DeficiencyHeadache & MigrainesVertigo & DizzinessSore Throat & StrepSwollen Tonsils & AdenoidsVison & Hearing IssuesLow Energy & FatigueDifficulty SleepingPain, Numbness & Tingling in Arms to HandsEpilepsy & SeizuresSensory & SpectrumADD / ADHDFocus & Memory IssuesAnxiety & StressBalance & CoordinationSpeech IssuesTMJ / Jaw PainStiff Neck & ShouldersDepressionHigh Blood PressurePoor Metabolism & Weight Control
REGION: UPPER THORACIC

Functions:
- Upper G.I
- Respiratory System
- Cardiac Function
PLEASE SELECT THE SYMPTOMS THAT YOU EXPERIENCED.

Reflux / GERDChronic Colds & CoughAsthmaBronchitis & PneumoniaFunctional Heart Conditions
PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING

Reflux / GERDChronic Colds & CoughAsthmaBronchitis & PneumoniaFunctional Heart Conditions
REGION: MID THORACIC

Functions:
- Major Digestive Center
- Detox & Immuniny
PLEASE SELECT THE SYMPTOMS THAT YOU EXPERIENCED

Gallbladder Pain / IssuesJaundiceFeverIndigestion & HeartburnStomach Pains & UlcersBlood Sugar Problems
PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING

Gallbladder Pain / IssuesJaundiceFeverIndigestion & HeartburnStomach Pains & UlcersBlood Sugar Problems
REGION: LOWER THORACIC

Functions:
- Stress Response
- Filtration & Elimination
- Gut & Digestion
- Hormonal Control
PLEASE SELECT THE SYMPTOMS THAT YOU EXPERIENCED

Behavior IssuesHyperactivityChronic FatigueChronic StressAllergies & EczemaSkin Conditions / RashKidney ProblemsGas Pain & Bloating
PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING

Behavior IssuesHyperactivityChronic FatigueChronic StressAllergies & EczemaSkin Conditions / RashKidney ProblemsGas Pain & Bloating
REGION: LUMBAR, SACRUM & PELVIS

Functions:
- Lower G.I (Absorption & Motility)
- Gut-Immune System
- Major Hormonal Control
PLEASE SELECT THE SYMPTOMS THAT YOU EXPERIENCED.

ConstipationChrohn's, Colitis & IBSDiarrheaBed-wettingBladder & Urination IssuesCramps & Menstrual IssuesCysts & EndometriosisInfertilityImportencyHermorrhoidsSciatica & Radiating PainLumbopelvic / ST Joint PainHamstring TightnessDisc DegenerationLeg Weakness & CrampsPoor Circulation & Cold FeetKnee, Ankle & Foot PainWeek Ankle & ArchesLower Back PainGlutein & Casein Intolerance
PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING

ConstipationChrohn's, Colitis & IBSDiarrheaBed-wettingBladder & Urination IssuesCramps & Menstrual IssuesCysts & EndometriosisInfertilityImportencyHermorrhoidsSciatica & Radiating PainLumbopelvic / ST Joint PainHamstring TightnessDisc DegenerationLeg Weakness & CrampsPoor Circulation & Cold FeetKnee, Ankle & Foot PainWeek Ankle & ArchesLower Back PainGlutein & Casein Intolerance
Patient Name
Date

MonthDayYear
Date
Should be Empty:

Adult Patient Questionnaire Pack Form

Confidential Patient Information

Current Health Conditions

Your Health Goals

Chiropractic History

TRAUMAS: Physical Injury History

TOXINS: Chemicals & Environmental Expose

THOUGHTS: Emotional Stresses & Challenges

Acknowledgement & Consent

Patient Review of Systems