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New Patient Only
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Patient Information
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Marital Status
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Employer
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Occupation
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City
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State
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ZIP
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Phone
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Spouse or parent's name
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Name of local primary Physician
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Where did you find us?
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Do you use online scheduling?
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Whom may we thank for referring you to us?
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Symptoms
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Main Complaint
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How often?
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How bad?
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Is it getting worse?
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When did it start?
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What activity bothers it the most?
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Getting better?
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When is it at its worst?
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When is it at its best?
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Rate the pain
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Other Chiropractors
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Positive experiences
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Other type of physician or therapist
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Positive experiences
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Secondary Complaint
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Health History (Circle all that apply)
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Women only
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How many children?
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Are you pregnant?
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Date of last Menstrual Cycle
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Nursing details
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Are you taking birth control pills?
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Previous Surgeries and Dates
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List All Medications you are currently taking
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What kind of exercise do you do?
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What supplements do you take?
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How much do you smoke per day?
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How much do you drink per day?
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Signature
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Below questionnaire only to be filled by existing patient
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Low Back Pain Disability Questionnaire
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Section 1 – Pain intensity
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Section 2 – Personal care (washing/dressing etc)
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Section 3 – Lifting
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Section 4 – Walking
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Section 5 – Sitting
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Section 6 – Standing
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Section 7 – Sleeping
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Section 8 – Sex life (if applicable)
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Section 9 – Social life
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Section 10 – Travelling
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SCORE
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Neck Pain Questionnaire
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Section 1 – Pain Intensity
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Section 2 – Personal Care
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Section 3 – Lifting
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Section 4 – Reading
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Section 5 – Headache
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Section 6 – Concentration
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Section 7 – Work
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Section 8 - Driving
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Section 9 – Sleeping
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Section 10 – Recreation
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SCORE
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Evidence of Functional Improvement
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Date of Injury
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Functional Improvement In Regards to Work Activities
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Since the most recent evaluation
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A. Ability to work has
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B. Work restrictions have
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C. Work output has
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D. Currently unable to do any work
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Currently on modified work duty
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E. Current work restrictions
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If yes, specify
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F. Currently working fewer hours
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How many hours currently working?
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Additional information
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Functional Improvement In Regards to Home/School/Recreational Activities
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Since the most recent evaluation
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A. Ability to lift has
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B. Ability to Sit longer has
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C. Ability to stand longer has
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D. Ability to walk further has
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E. Ability to use arms and hands has
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F. Ability to do recreational activities has
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G. Ability to do usual exercise routine
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H. Ability to care for your children
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Additional information
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Functional Improvement with Corrective Exercises
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With exercise rehab, since the last evaluation
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A. Neck strength has
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B. Low back strength has
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C. Abdominal strength has
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D. Strength has
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Which part?
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E. Strength has
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Which part?
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Additional information
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Rehab Progress (percent of goal obtained)
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Neck
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Back
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Abs
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Disability Indexes
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Disability Indexes, please select
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Other functional changes noted
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Only For Auto Insurance Information
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Please Read
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Policyholders Name
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Insurance Company's Name
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Policy #
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Claim #
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Med-Pay Coverage?
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Amount $
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Adjuster's Name
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Phone #
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Claims office address
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What was the date of the accident?
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What time did the accident occur?
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How many vehicles were involved in the accident?
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What was the estimated damage to the vehicle you were in?
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What state did the accident occur in?
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What city did the accident occur in?
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What street or intersection were you on when the accident occurred?
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What direction were you traveling in?
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What type of impact was the auto accident?
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Vehicle hit anything after the accident?
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If yes, please describe
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Where were you sitting in the vehicle during the accident?
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Did you know the accident was coming?
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What type of vehicle were you in?
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What type of vehicle impacted yours?
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At the time of impact, how fast was the vehicle moving?
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At the time of impact, how fast was the other vehicle moving?
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During/after crash what happened to your vehicle?
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Lose consciousness during the accident?
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How was your head positioned during the accident?
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How was your torso positioned during the accident?
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How were your hands positioned during the accident?
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Head hit anything during the accident?
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If yes, please describe
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Face hit anything during the accident?
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If yes, please describe
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Shoulders hit anything during the accident?
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If yes, please describe
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Neck hit anything during the accident?
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If yes, please describe
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Chest hit anything during the accident?
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If yes, please describe
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Hips hit anything during the accident?
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If yes, please describe
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Knees hit anything during the accident?
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If yes, please describe
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Feet hit anything during the accident?
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If yes, please describe
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What kind of headrest was in your vehicle?
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Where was the headrest positioned on your head?
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Have your seatbelt on during the accident?
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What was damaged in your vehicle?
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Items that denied inward
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Doors that would not open due to accident?
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Did you go to the hospital?
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If no, why?
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How did you get to the hospital?
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What was the name of the hospital?
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Were you hospitalized overnight?
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What you were prescribed at the hospital?
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Stitches for any cuts at the hospital?
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Were x rays taken at the hospital?
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If yes, which area was taken
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