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If last appointment was under 2 months ago, tap here for progress form
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- How do you feel today?
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1. Tap the button below and please circle on the body image provided, everywhere that you feel anything.
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2. Please select the BEST way or ways to describe your discomfort, pain or uncomfortable sensations:
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3. Pain Scale: Select a number that best describes your discomfort and/ or pain level TODAY: 1 = no pain, 10 = worst pain
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4. How often do you experience the pain or discomfort since it most recently started?
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If "multiple days per week" selected, please indicate how many days each week:
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If "multiple days per month" selected, please indicate how many days each month:
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5. When did this discomfort originally start?
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a. Is the flare-up from an old injury?
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b. When did the most recent flare-up start?
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How did the discomfort come on? (What happened?)
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7. Since your last visit, are you:
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If last appointment was 3 or more months in the past, or you have a new condition: tap here for history update form
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- History Update -
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Would you like for us to check on your insurance coverage?
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1. Primary Complaint/Symptom:
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2. All other Complaints/Symptoms:
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3. How did this happen?
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4. When did this happen?
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5. Did this happen at work or in an auto-accident?
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6. When was the accident?
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If a flare-up, when did the flare-up start?
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7. Are you taking any Prescription drugs or Over-the-counter drugs, supplements or vitamin? List all.
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8. Are you having trouble sleeping?
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Is the pain waking you at night?
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9. What makes it feel better?
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10. What makes it feel worse?
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11. Does it:
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Where?
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12. How often do you experience the pain or discomfort since it most recently started?
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If "multiple days per week" selected, please indicate how many days each week:
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If "multiple days per month" selected, please indicate how many days each month:
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13. Pain Scale: Select a number that best describes your discomfort and/ or pain level TODAY: 1 = no pain, 10 = worst pain
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14. Describe how your pain or discomfort feels (select all that apply)
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15. Since your last visit, are you:
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16. Tap the button below and circle on the images everywhere you feel anything
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Authorization: I authorize Back Pain Relief Chiropractic, LLC to treat my condition.
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I understand that I must pay for all services rendered at the time of service.
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Should I have insurance, I authorize Back Pain Relief Chiropractic, LLC to bill my insurance.
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If I have insurance, I will pay my deductible, co-pay and/or co-insurance today.
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Initial:
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- Functional Rating Index - For each item below, select the number which closely describes your condition right now
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1. Pain Intensity
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2. Sleeping:
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3. Personal Care (bathing, dressing, etc)
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4. Travel: (driving, etc)
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5. Work
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6. Recreation Activities:
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7. Frequency of Pain:
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8. Lifting
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9. Walking:
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10. Standing:
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Patient Signature & Date
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Staff Signature & Date
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All Patients, tap here to complete the section below:
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Symptoms: (Select all that apply)
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