New Patients

PATIENT INTAKE FORM

 

Patient Name:  _____________________________Date:  _______________

 

1. Is today's problem caused by:  □ Auto Accident       

 

2. Indicate on the drawings below where you have pain/symptoms

    

3. How often do you experience your symptoms?

                □ Constantly (76-100% of the time)                 □ Occasionally (26-50% of the time)

                □ Frequently (51-75% of the time)                   □ Intermittently (1-25% of the time)

 

4. How would you describe the type of pain?

                □ Sharp                                  □ Numb

                □ Dull                                     □ Tingly

                □ Diffuse                                               □ Sharp with motion

                □ Achy                                    □ Shooting with motion

                □ Burning                              □ Stabbing with motion

                □ Shooting                            □ Electric like with motion

                □ Stiff                                     □ Other:___________________

 

5. How are your symptoms changing with time?

□ Getting Worse                   □ Staying the Same                            □ Getting Better

 

6. Using a scale from 0-10 (10 being the worst), how would you rate your problem?

0     1     2     3     4     5     6      7     8      9     10 (Please circle)

 

7. How much has the problem interfered with your work?

□ Not at all             □ A little bit            □ moderately        □ Quite a bit          □ extremely

 

8. How much has the problem interfered with your social activities?

□ Not at all             □ A little bit            □ Moderately        Quite a bit              □ Extremely

 

9. Who else have you seen for your problem?

□ Chiropractor                      □ Neurologist                        □ Primary Care Physician

□ ER physician                     □ Orthopedist                        □ Other:_____________

□ Massage Therapist          □ Physical Therapist           □ No one

 

10. How long have you had this problem?___________

 

11. How do you think your problem began?

___________________________________________________________________________________

 

12. Do you consider this problem to be severe?

□ Yes                      □ Yes, at times                      □ No

 

13. What aggravates your problem?

____________________________________________________________________________________

 

14. What concerns you the most about your problem; what does it prevent you from doing?

____________________________________________________________________________________

 

15. What is your:  Height___________         Weight _____________                    Age ___________

                                Occupation _____________________________________________________

 

16. How would you rate your overall Health?

□ Excellent         □ Very Good         □ Good         □ Fair         □ Poor

 

17. What type of exercise do you do?

□ Strenuous            □ Moderate            □ Light            □ None

 

18. Indicate if you have any immediate family members with any of the following:

□ Rheumatoid Arthritis                                       □ Diabetes                            □ Lupus

□ Heart Problems                                               □ Cancer                               □ ALS

 

19.  For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past.  If you presently have a condition listed below, place a check in the "present" column.

Past  Present                                      Past   Present                                Past   Present

□         □ Headaches                            □          □ High Blood Pressure      □         □ Diabetes

□         □ Neck Pain                               □          □ Heart Attack                      □         □ Excessive Thirst

□         □ Upper Back Pain                   □          □ Chest Pains                      □         □ Frequent Urination

□         □ Mid Back Pain                       □          □ Stroke                                 □         □ Smoking/Tobacco Use

□         □ Low Back Pain                      □          □ Angina                               □         □ Drug/Alcohol Dependence

□         □ Shoulder Pain                       □          □ Kidney Stones                  □         □ Allergies

□         □ Elbow/Upper Arm Pain        □          □ Kidney Disorders            □         □ Depression

□         □ Wrist Pain                               □          □ Bladder Infection            □         □ Systemic Lupus

□         □ Hand Pain                              □          □ Painful Urination              □         □ Epilepsy

□         □ Hip Pain                                  □          □ Loss of Bladder Control □         □ Dermatitis/Eczema/Rash

□         □ Upper Leg Pain                     □          □ Prostate Problems          □         □ HIV/AIDS

□         □ Knee Pain                              □          □ Abnormal Weight Gain/Loss

□         □ Ankle/Foot Pain                     □          □ Loss of Appetite                    For Females Only

□         □ Jaw Pain                 □          □ Abdominal Pain               □         □ Birth Control Pills

□         □ Joint Pain/Stiffness              □          □ Ulcer                                   □         □ Hormonal Replacement

□         □ Arthritis                                    □          □ Hepatitis                            □         □ Pregnancy

□         □ Rheumatoid Arthritis            □          □ Liver/Gall Bladder Disorder

□         □ Cancer                                    □          □ General Fatigue

□         □ Tumor                                     □          □ Muscular In coordination

□         □ Asthma                                   □          □ Visual Disturbances

□         □ Chronic Sinusitis                   □          □ Dizziness

□         □ Other:____________________________

 

20. List all prescription medications you are currently taking:

_______________________________________________________________________________

 

21. List all of the over-the-counter medications you are currently taking:

________________________________________________________________________________

 

22. List all surgical procedures you have had:

________________________________________________________________________________

 

23. What activities do you do at work?

Sit:                                      □ Most of the day                      □ Half the day                 □ A little of the day

Stand:                                □ Most of the day                      □ Half the day                 □ A little of the day

Computer work:              □ Most of the day                      □ Half the day                 □ A little of the day

On the phone:                  □ Most of the day                      □ Half of the day             □ A little of the day

 

24. What activities do you do outside of work?

_________________________________________________________________________________

 

25. Have you ever been hospitalized?          □ No       □ Yes

If yes, why __________________________________________________________________________

 

26. Have you had significant past trauma?     □ No       □ Yes

 

27. Anything else pertinent to your visit today?______________________________________________

 

 

Patient Signature___________________________________   Date:____________________