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How did you hear about us?
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Name of friend or doctor that referred you?
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Have you had Chiropractic treatment before?
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If yes, what was the date of your last visit?
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Treating Condition History
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Main Medical Condition?
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Level of pain (1-10)
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What is mainly bothering you today?
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Please describe
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Condition onset by a work-related injury?
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If yes, are you unable to work due to your injury?
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Please describe the accident.
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What does quality of the the pain feel like?
• • •
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Other explanation of quality of pain
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Is the problem aggravated by
• • •
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Other activities that aggravate your condition
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Is the problem helped by
• • •
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Other things that alleviate your pain?
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Is your condition getting
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Please explain.
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Pain radiating down legs or arms?
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Please explain.
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Are you experiencing any numbness?
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Please explain.
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Do you have trouble sleeping?
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Please explain.
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Medical History
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Family medical history
• • •
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Did you ever have/had
• • •
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Inoculations you had
• • •
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Do you have any of the following other complaint
• • •
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Procedures/Surgeries
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Procedure/Surgery - 1
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Name & Date of the Procedure/Surgery?
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Name of Doctor
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Procedure/Surgery - 2
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Name & Date of the Procedure/Surgery?
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Name of Doctor
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Procedure/Surgery - 3
|
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Name & Date of the Procedure/Surgery?
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Name of Doctor
|
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Procedure/Surgery - 4
|
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Name & Date of the Procedure/Surgery?
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Name of Doctor
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Accidents/Falls
|
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Accident/Fall - 1
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Date & Description of Accident/Fall
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Name of Doctor's you treated with?
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Accident/Fall - 2
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Date & Description of Accident/Fall
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Name of Doctor's you treated with?
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Other conditions you are treating for
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Treated for a other conditions/problems?
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Any other health concerns?
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If yes, please list problems and Doctor.
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Medications
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Are you currently taking any medication?
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Medication - 1
|
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Medication name/purpose?
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Prescribing doctor?
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Medication - 2
|
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Medication name/purpose?
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Prescribing doctor?
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Medication - 3
|
|
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Medication name/purpose?
|
Prescribing doctor?
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Medication - 4
|
|
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Medication name/purpose?
|
Prescribing doctor?
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Medication - 5
|
|
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Medication name/purpose?
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Prescribing doctor?
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List supplements/herbs you are taking
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New Field
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New Field
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