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Seaside New Patient Form
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Marital Status
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Occupation
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Patient’s employer/School
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Employer/School Address
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Employer/School Phone
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Spouse’s Name
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Birth date
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SS#
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Spouse’s Employer
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Whom may we thank for referring you?
|
ACCIDENT INFORMATION
|
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Is condition due to an accident?
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Date
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Type of accident
|
To whom have you made a report of your accident?
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Attorney Name (if applicable)
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PATIENT CONDITION
|
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Reason for Visit
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When did your symptoms appear?
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What makes your symptoms better?
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What makes your symptoms worse?
|
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Activities or movements that are painful to perform
• • •
|
Type of Pain:
• • •
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Rate the severity of your pain
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How often do you have this pain?
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Is it constant or does it come and go?
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Does it interfere with your
• • •
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Do you have any secondary or additional complaints?
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Mark where your symptoms are located
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Health History
|
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What treatment have you received for your condition?
• • •
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Other
|
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Name and address of other doctor(s) who have treated you for this condition?
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Have you seen a chiropractor before?
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If yes, for what?
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Did it help?
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Indicate if you have/ had the following
|
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Current
• • •
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Other
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Past
• • •
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Other
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Family History
• • •
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Other
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Work Activity
• • •
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Exercise
• • •
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Type
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Habits
|
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Do you smoke?
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Packs per day?
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Quit/ Quitting smoking?
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Do you consume alcohol?
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drinks/week?
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Do you drink coffee?
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how many cups per day?
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Do you drink soda or caffeine drinks?
|
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how many drinks per day?
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Diet or Regular?
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High stress level?
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Reason
|
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Women: Are you pregnant?
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Due Date
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Injuries/surgeries you have had
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Falls (Describe)
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Date
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Head Injuries (Describe)
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Date
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Broken Bones (Describe)
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Date
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Dislocations (Describe)
|
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Date
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Surgeries (Describe)
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Date
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Auto Accidents (Describe)
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Date
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Vitamins/ Herbes/ Minerals
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Personal health goal
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Patient Health Information Consent
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New Spring- Therapeutic Massage
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Occupation
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Referred by
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Had a professional massage before?
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If yes, how often?
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Difficulty lying on your front, back, or side?
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If yes, please explain?
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Have any allergies to oils, lotions, ointments, fruits or nuts?
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If yes, please explain?
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Do you have sensitive skin?
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Are you wearing?
• • •
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Sit for long hours at a workstation, computer, or driving?
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If yes, please describe?
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Perform any repetitive movement in your work, sports, or hobby?
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If yes, please describe?
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Stress level affected your health?
• • •
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Other
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Specific area of the body where you are experiencing tension, stiffness, pain or discomfort?
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If yes, please identify?
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Particular goals in mind for this massage session?
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If yes, please explain?
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Specific areas you would like the massage therapist to concentrate on during the session
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Medical History
|
Currently or have you ever had any of the following:
• • •
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If pregnant, how many months?
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Currently under medical supervision?
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If yes, please explain?
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Do you see a chiropractor?
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If yes, how often?
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Are you currently taking any medication?
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If yes, please list
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Is there anything else about your health history that would be useful for your massage therapist to plan a safe session
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Please Read and Sign
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New Spring New Patient Form
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Height:
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Weight
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Marital Status:
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Spouse's Name:
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Number of Children:
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Complaint Information
|
|
What is the purpose of your visit?
|
What is the reason for this visit?
|
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Date of scheduled appointment
|
When did this condition begin?
|
|
How long have you had this condition?
|
What caused this condition?
|
|
Where is the discomfort?
|
Head
|
|
Neck
|
Back
|
|
Trunk
|
Upper Extremity
|
|
Lower Extremity
|
Does the discomfort radiate/travel?
|
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If yes, Where does the pain radiate to?
|
Describe the quality of the discomfort
• • •
|
|
Describe the onset of the discomfort
|
Describe the intensity of the discomfort
|
|
Rate the severity of your discomfort
|
How often do you feel this discomfort?
|
|
How has this complaint changed since the onset?
|
What activity is most significantly affected by this discomfort?
|
|
What aggravates this condition?
• • •
|
What improves this condition?
• • •
|
|
Treatment have you received for this condition up to now?
• • •
|
Diagnostic tests performed to assess this condition?
|
|
Had any previous episodes of this condition?
|
What ways does this condition affect your life and your ability to function?
• • •
|
|
Do you have an additional complaint? Complaint#2
|
Complaint #2 Information
|
|
What is the purpose of your visit?
|
What is the reason for this visit?
|
|
Date of scheduled appointment
|
When did this condition begin?
|
|
How long have you had this condition?
|
What caused this condition?
|
|
Where is the discomfort?
|
Head
|
|
Neck
|
Back
|
|
Trunk
|
Upper Extremity
|
|
Lower Extremity
|
Does the discomfort radiate/travel?
|
|
If yes, Where does the pain radiate to?
|
Describe the quality of the discomfort
• • •
|
|
Describe the onset of the discomfort
|
Describe the intensity of the discomfort
|
|
Rate the severity of your discomfort
|
How often do you feel this discomfort?
|
|
How has this complaint changed since the onset?
|
What activity is most significantly affected by this discomfort?
|
|
What aggravates this condition?
• • •
|
What improves this condition?
• • •
|
|
Treatment have you received for this condition up to now?
• • •
|
Diagnostic tests performed to assess this condition?
|
|
Had any previous episodes of this condition?
|
What ways does this condition affect your life and your ability to function?
• • •
|
|
Additional Complaint: Complaint #3
|
What is the purpose of your visit?
|
|
What is the reason for this visit?
|
Date of scheduled appointment
|
|
When did this condition begin?
|
How long have you had this condition?
|
|
What caused this condition?
|
Where is the discomfort?
|
|
Head
|
Neck
|
|
Back
|
Trunk
|
|
Upper Extremity
|
Lower Extremity
|
|
Does the discomfort radiate/travel?
|
If yes, Where does the pain radiate to?
|
|
Describe the quality of the discomfort
• • •
|
Describe the onset of the discomfort
|
|
Describe the intensity of the discomfort
|
Rate the severity of your discomfort
|
|
How often do you feel this discomfort?
|
How has this complaint changed since the onset?
|
|
What activity is most significantly affected by this discomfort?
|
What aggravates this condition?
• • •
|
|
What improves this condition?
• • •
|
Treatment have you received for this condition up to now?
• • •
|
|
Diagnostic tests performed to assess this condition?
|
Had any previous episodes of this condition?
|
|
What ways does this condition affect your life and your ability to function?
• • •
|
Additional Complaint # Complaint # 4
|
|
What is the purpose of your visit?
|
What is the reason for this visit?
|
|
Date of scheduled appointment
|
When did this condition begin?
|
|
How long have you had this condition?
|
What caused this condition?
|
|
Where is the discomfort?
|
Head
|
|
Neck
|
Back
|
|
Trunk
|
Upper Extremity
|
|
Lower Extremity
|
Does the discomfort radiate/travel?
|
|
If yes, Where does the pain radiate to?
|
Describe the quality of the discomfort
• • •
|
|
Describe the onset of the discomfort
|
Describe the intensity of the discomfort
|
|
Rate the severity of your discomfort
|
How often do you feel this discomfort?
|
|
How has this complaint changed since the onset?
|
What activity is most significantly affected by this discomfort?
|
|
What aggravates this condition?
• • •
|
What improves this condition?
• • •
|
|
Treatment have you received for this condition up to now?
• • •
|
Diagnostic tests performed to assess this condition?
|
|
Had any previous episodes of this condition?
|
What ways does this condition affect your life and your ability to function?
• • •
|
|
Auto Accident / slip /trip /fall Injuries
|
The injury was due to:
|
|
What date did the accident happen?
|
How did the injury occur?
• • •
|
|
As a pedestrian, what were you doing at the time of the accident?
|
Were you wearing a seatbelt?
|
|
Where in the vehicle were you when the accident happened?
|
Did the airbag deploy?
|
|
Come in contact with anything at the time of the collision?
|
What interior vehicle part did you come into contact with?
• • •
|
|
What part of your body made contact?
• • •
|
Where in the vehicle were you when the accident happened?
|
|
What type of protection did you have?
• • •
|
What did you come into contact with at the time of the collision?
• • •
|
|
Where were you looking at the time of impact?
|
Did you receive an injury to the head?
|
|
Did you lose consciousness?
|
What part of your vehicle was impacted?
• • •
|
|
In what direction was your vehicle moving?
|
What was the estimated speed of your vehicle?
|
|
What was the extent of the damage to your vehicle?
|
What was the extent of the damage to the other vehicle?
|
|
In what direction was other vehicle moving?
|
What was the estimated speed of other vehicle?
|
|
Was your vehicle towed from the scene?
|
Did police arrive at the scene?
|
|
Was an accident report taken?
|
Did Emergency Medical Services arrive at the scene?
|
|
Were you transported to a medical facility (ER or hospital)?
|
Have you received any treatment since the accident?
• • •
|
|
What was the location of symptoms felt at the time of the accident?
|
Head
• • •
|
|
Neck
• • •
|
Back
• • •
|
|
Trunk
• • •
|
Upper Extremity
• • •
|
|
Lower Extremity
• • •
|
Describe the discomfort felt at the time of the accident.
• • •
|
|
Additional symptoms which appeared since the accident happened?
• • •
|
Describe the status of your symptoms since the accident.
• • •
|
|
Review of Systems
|
Musculoskeletal
• • •
|
|
Neurological
• • •
|
Head, Eyes, Ears, Nose and Throat
• • •
|
|
Cardiovascular
• • •
|
Respiratory
• • •
|
|
Gastrointestinal
• • •
|
Genitourinary
• • •
|
|
Endocrine
• • •
|
Dermatological and Bleeding
• • •
|
|
Past, Family and Social History
|
Did you have a surgical history?
|
|
If yes, List your (or the patient's) past surgical history
|
Abdominal aortic aneurysm repair
|
|
Date
|
Appendectomy
|
|
Date
|
Biopsy
|
|
Date
|
Bunionectomy
|
|
Date
|
Cardiac bypass
|
|
Date
|
Cardiac valve replacement
|
|
Date
|
Carpal tunnel - left
|
|
Date
|
Carpal tunnel - right
|
|
Date
|
Cataract - left
|
|
Date
|
Cataract - right
|
|
Date
|
C-section
|
|
Date
|
Cosmetic - face lift
|
|
Date
|
Cosmetic - nose
|
|
Date
|
Cosmetic - breast reduction or enlargement
|
|
Date
|
Cosmetic - tummy tuck
|
|
Date
|
Cosmetic - other
|
|
Date
|
Ear tubes
|
|
Date
|
Gall bladder removed
|
|
Date
|
Gastric bypass
|
|
Date
|
Hysterectomy - complete
|
|
Date
|
Hysterectomy - partial
|
|
Date
|
Knee - left
|
|
Date
|
Knee - right
|
|
Date
|
Lasik
|
|
Date
|
Mastectomy
|
|
Date
|
Shoulder - left
|
|
Date
|
Shoulder - right
|
|
Date
|
Thyroidectomy
|
|
Date
|
Tonsils
|
|
Date
|
Tonsils & adenoids
|
|
Date
|
Wisdom teeth
|
|
Date
|
Discectomy level
|
|
Date
|
Implants
|
|
Date
|
Ganglion cyst
|
|
Date
|
Spinal fusion
|
|
Date
|
Transplant
|
|
Date
|
OTHER
|
|
Date
|
Did you have any Past Illnesses?
|
|
If yes, please describe
|
AIDS/HIV
|
|
Age:
|
Alcoholism
|
|
Age:
|
Alzheimer's
|
|
Age:
|
Anemia
|
|
Age:
|
Anorexia
|
|
Age:
|
Arthritis
|
|
Age:
|
Asthma
|
|
Age:
|
Bleeding disorders
|
|
Age:
|
Breast lump
|
|
Age:
|
Bronchitis
|
|
Age:
|
Bulimia
|
|
Age:
|
Cancer
|
|
Age:
|
Explain:
|
|
Chemical dependency
|
Age:
|
|
Congenital anomaly
|
Age:
|
|
Explain:
|
Depression
|
|
Age:
|
Diabetes
|
|
Age:
|
Emphysema
|
|
Age:
|
Epilepsy
|
|
Age:
|
Extremity issues
|
|
Age:
|
Explain:
|
|
Fracture
|
Age:
|
|
Explain:
|
Heart disease
|
|
Age:
|
Hepatitis
|
|
Age:
|
Hereditary disorder
|
|
Age:
|
Explain:
|
|
Hernia
|
Age:
|
|
Herniated disc
|
Age:
|
|
Explain:
|
High blood pressure
|
|
Age:
|
High cholesterol
|
|
Age:
|
Hospitalization
|
|
Age:
|
Kidney disease
|
|
Age:
|
Liver disease
|
|
Age:
|
Migraine headaches
|
|
Age:
|
Miscarriage
|
|
Age:
|
Multiple sclerosis
|
|
Age:
|
Natural labor
|
|
Age:
|
Neuromuscular issues
|
|
Age:
|
Explain:
|
|
Osteoarthritis
|
Age:
|
|
Osteoporosis
|
Age:
|
|
Pacemaker
|
Age:
|
|
Parkinson's disease
|
Age:
|
|
Pinched nerve
|
Age:
|
|
Pneumonia
|
Age:
|
|
Polio
|
Age:
|
|
Previous chiropractic care
|
Age:
|
|
Prostate problems
|
Age:
|
|
Psychiatric care
|
Age:
|
|
Rheumatoid arthritis
|
Age:
|
|
Stroke
|
Age:
|
|
Suicide attempt
|
Age:
|
|
Thyroid problems
|
Age:
|
|
Trauma/injury
|
Age:
|
|
Explain:
|
Tumor
|
|
Age:
|
Ulcers
|
|
Age:
|
Vaginal infection
|
|
Age:
|
Venereal disease
|
|
Age:
|
OTHER
|
|
Age:
|
Number of children:
|
|
Number of pregnancies
|
Number of deliveries
|
|
List any past history of accidents or trauma
• • •
|
Are you presently taking any medication?
|
|
Medications are you presently taking?
• • •
|
List patient's family health history (only blood relatives)
• • •
|
|
What are your current work habits?
• • •
|
Describe your personal social habits?
• • •
|
|
Describe your present exercise habits?
• • •
|
Describe your diet and nutritional status?
• • •
|
|
Draw Your Symptoms
|
Employment Information
|
|
Regular Work Status:
|
Employer Name:
|
|
Employer Address:
|
Occupation:
|
|
Supervisor Name:
|
Supervisor Phone/Extension:
|
|
Physical Work Duties:
|
What is the purpose of your visit?
|
|
Chiropractic Experience
|
Who referred you to our office?
|
|
Where did you hear about us?
• • •
|
Other:
|
|
Been adjusted by a chiropractor before?
|
If yes, what is the reason?
|
|
Doctor's Name:
|
Approximate date of last visit:
|
|
Member of your family ever seen a wellness chiropractor?
|
Goals for Your Care
• • •
|
|
Additional information
|
Smoking Status
|
|
Type of Tobacco:
• • •
|
Have you tried to quit?
|
|
How much tobacco do you use?
|
How long have you used tobacco?
|
|
Do you consume alcohol?
|
drinks/week?
|
|
Do you drink coffee?
|
how many cups per day?
|
|
Do you drink soda or caffeine drinks?
|
how many drinks per day?
|
|
Diet or Regular?
|
High stress level?
|
|
Reason
|
Women: Are you pregnant?
|
|
Due Date
|
Neck Disability Index
|
|
Section 1: Pain Intensity
|
Section 2: Personal Care (Washing, Dressing, etc.)
|
|
Section 3: Lifting
|
Section 4: Reading
|
|
Section 5: Headaches
|
Section 6: Concentration
|
|
Section 7: Work
|
Section 8: Driving
|
|
Section 9: Sleeping
|
Section 10: Recreation
|
|
Score:
|
Transform to percentage score x 100 =
|
|
Oswestry Low Back Pain Disability Questionnaire
|
|
|
I have “Chronic Pain” or pain that has bothered me for 3 months or more:
|
|
|
Section 1: Pain Intensity
|
Section 2: Personal Care
|
|
Section 3: Lifting
|
Section 4: Walking
|
|
Section 5: Sitting
|
Section 6: Standing
|
|
Section 7: Sleeping
|
Section 8: Sex Life
|
|
Section 9: Social Life
|
Section 10: Traveling
|
|
Score:
|
|
