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:____________________