EmailMeForm
Patient Intake Form
Basic patient information
Name
*
First
Last
Birthdate
*
MM
/
DD
/
YYYY
Street Address
*
Address Line 2
City
*
Zip Code
*
Home Phone
###
-
###
-
####
Cell Phone
###
-
###
-
####
Email
Would you like appointment reminders by
(Check all that apply)
Text
E-mail
Problem Description
Please tell us as much as possible so we can help you as best as we can.
When was the last time you saw a chiropractor?
*
Please select one
I've never been to a chiropractor before.
Within the last year.
Within the last 5 years.
10 years or longer.
How did your symptom(s) begin?
*
No symptoms, just a tune-up.
Gradually worsened.
I don't know.
car accident (date below)
I had a specific Injury (date)
Current complaints, if any.
Headaches
Neck Pain
Mid Back Pain
Numbness Arms/Hands
Tingling Arms/Hands
Low Back Pain
Numbness Legs/Feet
Tingling Legs/Feet
Other
Headaches
Please select a value 0-10
0
1
2
3
4
5
6
7
8
9
10
Neck Pain
Please select a value 0-10
0
1
2
3
4
5
6
7
8
9
10
Upper Back Pain
Please select a value 0-10
0
1
2
3
4
5
6
7
8
9
10
Mid Back Pain
Please select a value 0-10
0
1
2
3
4
5
6
7
8
9
10
Lower Back Pain
Please select a value 0-10
0
1
2
3
4
5
6
7
8
9
10
Shoulder Pain
Please select a value 0-10
0
1
2
3
4
5
6
7
8
9
10
Knee Pain
Please select a value 0-10
0
1
2
3
4
5
6
7
8
9
10
Foot Pain
Please select a value 0-10
0
1
2
3
4
5
6
7
8
9
10
Other (described above)
Please select a value 0-10
0
1
2
3
4
5
6
7
8
9
10
How often are your symptoms present?
0-25%
26-50%
51-75%
76-100%
How much has your pain interfered with your daily activities?
0= No interference
10= Unable to carry on any activities
*
Please select a value 0-10
0
1
2
3
4
5
6
7
8
9
10
Please give as much information about how or why your symptom(s) (if any) started. Determining how your problem began can help us treat you more accurately.
How long have you had this/these symptom(s)?
Please select
No symptoms, just an adjustment.
Last few days
About a week.
A month or longer
For years
All my life
If this is not a new injury, what have you done for it so far, or in the past that has been helpful. For instance, physical therapy, medication, chiropractic, home exercise, etc. Please specify what was helpful, what was not.
N/A
Please check all of the following that apply to you:
Alcohol/Drug Dependence
Diabetes
High Blood Pressure
Stroke
Corticosteroid Use
Taking Birth Control Pills
Dizziness/Fainting
Numbness in Groin/Buttocks
Cancer/Tumor
Osteoporosis
Epilepsy/Seizures
Prostate Problems
Menstrual Problems
Urinary Problems
Currently Pregnant
Abnormal Weight Gain
Abnormal Weight Loss
Marked Morning Pain/Stiffness
Pain Unrelieved by Position or Rest
Pain at Night
Visual Disturbances
Tobacco Use
Neuropathy
Other
Desired activities that you are having difficulty doing that are affecting your quality of life. Please check all of the following that apply to you:
I'm having difficulty with...
doing my work/job duties
doing my household duties
working out
running
walking
playing w/ kids or grandkids
intimacy w/ significant other
sports activities
driving
hobbies
golf
swimming
bowling
riding bikes
dining out
going to movies
sitting
standing
bending
using the bathroom
showering
taking care of my kids
taking care of myself
Other
Medications? If not applicable, please leave N/A or none.
*
Other Health Problems?
Family History
*
Cancer
Diabetes
High Blood Pressure
Heart Problems/Stroke
Reumatoid Arthritis
No Significant Health Problems
Other
Anything else you think the doctor should know?
Specific details you would like during your treatment (if applicable)? (For instance, I prefer using an instrument to be adjusted, I do not want to be "cracked", or "I'm difficult to adjust."
Do you have any other specific questions/problems that you would like the doctor to address that you have not already informed us about?
I'm interested in
Chiropractic
Massage
Herbal Medicine
Weight Loss
Orthotics-Foot Pain
Home TENS Unit
How did you hear about us?
Did you hear about us from Yelp, Google, a friend, your MD, family member, somewhere else?
