First Name
Last Name
Birthdate
Email
Address
City
Zip
State
Phone (Home/Mobile)
Height
Weight
Patient Sex
Male
Female
Do you have health insurance?
Yes
No
Insurance Company Name
Member ID Number
Occupation
Emergency Contact No.
Emergency Contact
Relation
Current Complaint
Special location of the pain
How did this begin?
Date of Injury:
Date of symptoms appeared
Quality of Pain
Check all that apply
Aching
Burning
Crushing
Dull
Sharp
Stabbing
Shooting
Throbbing
Numbing
Weakness
Tingling
Other
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Intensity of Pain
Select one from level 1-10
1
2
3
4
5
6
7
8
9
10
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Frequency of Pain
Select the frequency of pain
Constant (76%-100%)
Frequently (51%-75%)
Intermittently (0%-25%)
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How much have your symptoms interfered with your daily activities?
Select one
Not at all
A little bit
Moderately
Quite a bit
Extremely
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What makes the condition feel better?
Select all that apply
Ice
Heat
Movement
Lying Down
Standing
Sitting
Changing Positions
Rest
Walking
Chiropractic Care
Massage
Medication
None of the above
Other
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What makes the condition feel worse?
Please select
Ice
Heat
Movement
Lying Down
Sitting
Standing
Changing positions
Walking
Bending/Twisting
None of the above
Other
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Associated Symptoms
Select all that apply
Numbness
Tingling
Weakness
Dizziness
Loss of Bowel/Bladder Control
Change in Vision
Extreme weight Gain or Loss
None
Other
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Other
Past Medical History
Smoking History
Never smoker
Past smoker
Current smoker
Have you ever been under chiropractic care?
Yes
No
What medications are you taking?
Current Allergies
Water Consumption
Average hours of sleep per night
Current Health Concerns and Problems
Please select all that apply
Unexplained weight loss
Excessive fatigue
Headaches
Migraines
Chronic nasal discharge
Abdominal pain
Loss of appetite
Blood in stool
Chronic cough
Asthma
Shortness of breath
Any heart trouble
Pain or pressure in chest
High blood pressure
Anemia
Excessive bleeding/bursting
Swelling of lymph glands
Memory loss
Fainting & dizziness
Slurred speech
Breast lumb
Breast nipple discharge
Breast nipple inversion
Frequent or painful urination
Difficulty start/stop urine flow
Excessive thirst or hunger
Difficulty holding urine or bowel movement
Cold or heat intolerance
Pain in the joints
Red inflamed joints
Chronic back pain
Painful periods
Inconsistent menstrual cycles
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