EmailMe Form - NEW PATIENT INTAKE FORM

Today's Date
MM / DD / YYYY
Name
First MI Last
Is today's problem caused by:
Auto Accident
Workman's Compensation
Other
Please explain in detail the MAIN REASON for today's visit:
How often do you experience your symptoms?
Constantly (76-100% of the time)
Frequently (51-75% of the time)
Occasionally (26-50% of the time)
Intermittently (1-25% of the time)
How would you describe the type of pain?
Sharp
Dull
Diffuse
Achy
Burning
Shooting
Stiff
Numb
Tingly
Sharp with motion
Stabbing with motion
Other
How are your symptoms changing with time?
Getting worse
Staying the same
Getting Better
On a scale of 1-10 (with 10 being the worst) how would you rate your problem?
How much has the problem interfered with your WORK?
Not at all
A little bit
Moderately
Quite a bit
Extremely
I don't work
How much has the problem interfered with your SOCIAL ACTIVITIES?
Not at all
A little bit
Moderately
Quite a bit
Extremely
I don't participate in any social activities
Who else have you seen for this problem? (Mark ALL that apply)
Another Chiropractor
ER Physician
Massage Therapist
Neurologist
Orthopedist
Physical Therapist
Primary Care Physician
Other
No One
How are your symptoms changing with time?
Getting worse
Staying the same
Getting Better
How long have you had this problem?
How do you think your problem began?
Do you consider this problem to be severe?
Yes
Yes, at times
No
What aggravates your problem?
What alleviates your problem?
What concerns you the most about your problem; what does it prevent you from doing?
Your Date of Birth:
MM / DD / YYYY
Your OCCUPATION?
How would you rate your overall health?
Excellent
Very Good
Fair
Poor
What type of exercise do you do?
Strenuous
Moderate
Light
None
Please indicate if you have any immediate family members with any of the following:
Rheumatoid Arthritis
Heart Problems
Diabetes
Cancer
Lupus
ALS

For each of the conditions listed below, mark if you currently have this condition, if you have in the past, or both.

	Currently Have	Have Had In The Past	Both
Headaches
Neck Pain
Upper Back Pain
Mid Back Pain
Shoulder Pain
Elbow/Upper Arm Pain
Wrist Pain
Hand Pain
Hip Pain
Upper Leg Pain
Knee Pain
Ankle/Foot Pain
Jaw Pain
Joint Pain/Stiffness
Arthritis
Rheumatoid Arthritis
Cancer
Tumor
Asthma
Chronic Sinusitis
High Blood Pressure
Heart Attack
Chest Pains
Stroke
Angina
Kidney Stones
Bladder Infection
Painful Urination
Loss of Bladder Control
Prostate Problems
Abnormal Weight Gain/Loss
Loss of Appetite
Abdominal Pain
Ulcer
Hepatitis
Liver/Gall Bladder Disorder
General Fatigue
Muscular Incoordination
Visual Disturbances
Dizziness
Diabetes
Excessive Thirst
Frequent Urintion
Smoking/Tobacco Use
Drug/Alcohol Dependence
Allergies
Depression
Systemic Lupus
Epilepsy
Dermatitis/Exzema/Rash
HIV/AIDS
Females Only: Birth Control Pills
Females Only: Hormonal Replacement
Females Only: Pregnancy

List all prescription and over the counter medications you are currently taking:
List all supplements you are currently taking:
List all surgical procedures you have had:
What activities do you do at work:

Most of the day Half of the day A little of the day

Sit

Stand

Computer work

On the phone:

Lifting
What activities do you do outside of work?
Have you ever been hospitalized? If yes, why?
Have you seen a chiropractor before? If yes, were your results good, fair, or poor?
Have you had significant past trauma? If yes, please explain.
Have you had any allergic reactions to medications; if so, what was your reaction?
Is there anything else pertinent to your visit today?
Signature
Clear

	Most of the day	Half of the day	A little of the day
Sit
Stand
Computer work
On the phone:
Lifting