Intake Form

1PATIENT INFO

2HEALTH INFO

3FAMILY INFO

4OTHER INFO

5INSURANCE INFO

CONFIDENTIAL PATIENT CASE HISTORY

Dear Patient:
Please complete this questionnaire. Your answers will help us to determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. THANK YOU.

Name(Required)

First Last

Social Security Number(Required)

Email Address(Required)

Address(Required)

Street Address City State ZIP / Postal Code

Primary Phone Number(Required)

Cell Phone Number

Work Phone Number

Age(Required)

Birth Date(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Occupation(Required)

Marital Status(Required)

Married

Single

Widowed

Divorced

Number of Children

Name of Spouse

Referred By

What is your major complaint?(Required)

Other complaints

Where is the symptom?(Required)

When did the symptom first start?(Required)

Have you had this or similar conditions in the past?(Required)

Please list numbers from the diagram above representing the area(s) of your discomfort.(Required)

How would you describe your pain?(Required)

Check more than one if necessary to describe your problem

Stiffness

Weakness

Sharp

Dull

Burning

Numbness & Tingling

Pressure

Throbbing

Tearing

Achy

Soreness

Travels

Constant

Comes & Goes

Making a Grinding Noise

Knot

When at it's worst rate the severity of your problem:(Required)

1 = Best 10 = Worst

1	2	3	4	5	6	7	8	9	10

What activities aggravate your condition? ((Required)

Check more than one if necessary to describe your problem

Working

Lifting

Stooping

Standing

Bending

Coughing

Lying down

Trying to Sleep

Walking

Chores

Stress

Movement

Standing after Sitting

Sitting down after Standing

Flexion

Extension

Turning Left

Turning Right

Bending Left

Bending Right

It interferes with:(Required)

Work

Sleep

Walking

Sitting

Hobbies

Leisure

What alleviates your condition?(Required)

Check more than one if necessary to describe your problem

Resting

Sitting

Standing

Using Ice

Using Heat

Stretching

Moving Around

Adjustments

OTC Medication

Laying down

Massage

Prescription Medication

Taking Time off Work

Sleeping

Exercising

How long has it been since you really felt good?(Required)

Other doctors who treated this condition

List surgical operations and years:

Age of Mattress:(Required)

Is Your Mattress

Comfortable

Uncomfortable

Date of Last Physical Exam

If unsure leave empty and select the next box

MM slash DD slash YYYY

Physical Exam Date

Unsure

Drugs you now take:(Required)

Pain Killers

Nerve Pills

Muscle Relaxers

Insulin

Hormones

Tranquilizer

Birth Control

Mood Related Drugs

Blood Pressure Medication

Other

N/A

Other: Please List(Required)

Is there any chance that you may be pregnant?(Required)

Yes

N/A

At our office we are not only interested in your well being, but also the health and well being of your family and loved ones. Please mention below any health conditions or concerns you may have about your:

Children

Spouse

Mother/Father

Siblings

Family Health Information

Many health problems are the result of hereditary spinal weaknesses; thus information about your family members will give us a better picture of your total health

NAME

RELATION

PAST AND PRESENT HEALTH PROBLEMS

Have you been in an auto accident?(Required)

Past Year

Past 5 Years

Over 5 years

Never

Describe(Required)

Have you had any personal injury or accident?(Required)

Past Year

Past 5 Years

Over 5 years

None

Describe(Required)

Childhood Years

Did you have any childhood illness?(Required)

Yes

Unsure

Was there a prolonged use of medicine?(Required)

Yes

Unsure

Did you have any falls from height Over 3 feet (i.e. crib, bunks)(Required)

Yes

Unsure

Did you play youth sports?(Required)

Yes

Unsure

Did you take/ use any drugs?(Required)

Yes

Unsure

Adult Years (18-present)

Do/Did you smoke?(Required)

Yes

Unsure

Do/ Did you drink alcohol?(Required)

Yes

Unsure

Have you been in any accidents?(Required)

Yes

Unsure

Do/Did you play adult/extreme sports?(Required)

Yes

Unsure

Have you suffered from?(Required)

Arthritis

Fatigue

Asthma

Sinus Trouble

Sleep Disorders

Digestive Disorders

Allergies

Heart Trouble

Diabetes

Numbness in fingers/hands

Headaches

Neck Pain

Pain between shoulders

Shoulder pain

Arm Pain

Elbow Pain

Hand/finger/wrist pain

Carpal Tunnel

Low Back Pain

Mid Back Pain

Backaches

Hip Pain / Thigh Pain

Knee Pain

Pain Down Back or Leg

Numbness in toes/feet

Concentration Problems

Menstrual pain/irregular

Pins & Needles

Cold Feet /Cold Hands

Dizziness

Loss of Balance

Ringing/Buzzing ears

Mood Swings /Depression

Tension

Nervousness

Other

Other: Please Describe(Required)

Is your condition due to an auto accident or job related injury?(Required)

Yes

Are you covered by Medicare?(Required)

Yes

Medicare Health Insurance Number(Required)

Consent(Required)

I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this Chiropractic Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this Chiropractic office will be credited my account or receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care, any fees for professional services rendered me will be immediately due and payable.

I agree

Today's Date(Required)

MM slash DD slash YYYY

Signature(Required)

CONFIDENTIAL PATIENT CASE HISTORY

Childhood Years

Adult Years (18-present)

Schedule a Consultation