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Chiropractic Intake Form
Section 1: Who Are You?
Email (for communication w/ doctor only):
Join our mailing List?
Occupation
How did you hear about us?
Other
Section 2: How Can We Help?
What is the primary reason for your visit?
What are your primary goals?
• • •
Any specific goals? I want to be able to
Have you seen a chiropractor?
Date of last visit?
Additional goals you are interested in?
• • •
Other
Section 3: Tell us About your Primary Issue
How long ago did it begin?
Was this a result of a car accident or accident at work?
If not, was there a known cause?
Is there anything that makes it better?
• • •
Other
Is there anything that makes it worse?
• • •
Other
Have you seen other practitioners for this?
• • •
Does the discomfort refer / travel anyplace else?
where?
• • •
How intense is the discomfort? (check multiple if it varies)
• • •
How often do you feel it?
hours per day
days per week
days per month
Section 4: About Your Health
Height:
Weight:
Blood pressure (if known):
Tobacco usage
day/week/mo
Alcohol usage
day/week/mo
Current medications or treatments:
ALL known allergies, drug or common:
Past surgeries and approximate dates:
History of major trauma or illness:
Current or past issues with the following body systems:
Eyes
Please describe
Ears
Please describe
Nose
Please describe
Throat
Please describe
Skin
Please describe
Hair
Please describe
Nails
Please describe
Bones
Please describe
Joint
Please describe
Heart
Please describe
Lung
Please describe
Digestive system
Please describe
Nervous system
Please describe
Vascular system
Please describe
Urinary system
Please describe
Respiratory system
Please describe
Urinary system
Please describe
Endocrine system
Please describe
Reproductive system
Please describe
Diabetes
Please describe
Neuropathy
Please describe
Osteoporosis/penia
Please describe
At times we may be having direct contact with you skin during examination and treatment.
Have any condition which is communicable through skin-on-skin contact or any other blood borne condition?
Acupuncture Intake
Section 1: Who Are You?
Email (for communication w/ doctor only):
Join our mailing List?
Have you been treated by Acupuncture before
Occupation
Marital Status
Children? Number/Ages
How did you hear about us?
Who can we thank for the referral?
Section 2: How Can We Help?
Complaint(s) / Concern(s)
Primary Complaints / Concerns
When Did This Start
Heat Makes It
Cold Makes It
Damp Weather Makes It
Exercise/Activity Makes It
Other (please specify)
Other Makes It
Secondary Complaints / Concerns
When Did This Start
Heat Makes It
Cold Makes It
Damp Weather Makes It
Exercise/Activity Makes It
Other please specify
Other Makes It
Additional Complaints / Concerns
Musculoskeletal Pain and Discomfort
Areas of Discomfort
Head
• • •
Amount of pain
Neck
• • •
Amount of pain
Jaw
• • •
Amount of pain
Shoulder
• • •
Amount of pain
Arm
• • •
Amount of pain
Elbow
• • •
Amount of pain
Wrist
• • •
Amount of pain
Hand
• • •
Amount of pain
Upper back
• • •
Amount of pain
Chest
• • •
Amount of pain
Abdomen
• • •
Amount of pain
Lower back
• • •
Amount of pain
Hip
• • •
Amount of pain
Thigh
• • •
Amount of pain
Knee
• • •
Amount of pain
Ankle
• • •
Amount of pain
Other please specify
Amount of pain
Medical History
Have you seen a physician in the last year
If yes please explain
Physician’s name
Approximate date of most recent exam/visit?
Past or Current Conditions
Cancer
• • •
Type
When
Hepatitis
• • •
High blood pressure
• • •
Hormonal Endocrine Disorders
• • •
Type
When
Rheumatic fever
• • •
When
Infectious diseases
• • •
Type
When
Diabetes
• • •
Type
When
Heart disease
• • •
Type
When
Seizures
• • •
Type
When
Autoimmune disorders
• • •
Type
When
Emotional disorders
• • •
Type
When
Tuberculosis
• • •
When
Sexually transmitted diseases
• • •
Type
When
Usage and Frequency of the Following
Coffee/black tea
Amount
Recreational drugs
Amount
Tobacco
Amount
Alcohol
Amount
Soda
Amount
Binge eating
Amount
Are you in recovery? Sober since
Would you like support on cutting back on any addictive habits
Do you have a special diet now or in the past
I have a pacemaker
I have known allergies
If yes, please list the allergies
I am taking lithium (Eskalith, LIthobid, Lithonate, Lithotabs)
I am taking Coumadin/Warfarin/Plavix
Do you exercise regularly
If so, what
Major Surgeries or Hospitalizations
How Often
Other Illnesses or Injuries
When
Current Medications
Reason for intake
Dosage
Rx/Supplement/Herbs
Reason for intake
Lifestyle Stresses or Concerns
• • •
Body Systems Assessment
How warm/cold do you feel (not in degrees) relative to other people? 1 being cold and 10 being hot
Pick the symptoms you have with temparature
• • •
If picked unusual sweats is it on AM/PM
Where on body (Sweat)
Your overall body moisture (hair, skin, mouth, bowels, etc.)
Your overall body moisture (hair, skin, mouth, bowels, etc.)
Pick the symptoms you have with moisture
• • •
Please specify Edema/swelling in which part of the body
Digestion Score 1 being Diarrhea and 10 being Constipation
Bowel Movements: How often?
Stools keep shape
Pick the symptoms you have with digestion
• • •
Energy level 1 being Low and 10 being High
Pick the symptoms you have with energy
• • •
Please specify the time of sudden energy drop
Please specify headaches _____/Wk
Hours of sleep per night
Sleep Difficulty
• • •
Wake ___x night
@_____ (am/pm)
Wake to urinate, How often?
Disturbing Dreams
Restless sleep
Groggy upon waking
Please specify the color of Phlegm
Eyes, Ears, Nose, Throat
• • •
Emotions
• • •
Urinary Issues
• • •
Female Health
Age of 1st Period (menarche)
Are you pregnant
# of pregnancies
Age of last period (menopause)
# of live births
# of abortions
# of miscarriages
Number of days between periods
Number of days of flow
Flow
Date of last: Gynecologic exam
Pap Smear
Bone Density scan
Mammogram
Male Health
Date of last prostate check up
PSA results
Manual prostate exam results
Lab results
Frequency of Urination
Color of urine
Anything else you would like us to know?
Amount
Type
When
Additional Free Field Notes
Color of urine
Odor
Symptoms related to prostate
• • •
Other please specify
Anything else you would like us to know?
Massage Intake Form
Have you had professional massage / bodywork before?
When was the last time?
Current pregnancy or breast feeding
• • •
List any previously broken bones
List any previous neck or spinal injuries
List any allergies
Are you diabetic?
Are you diabetic?
List any swollen joints
Headache frequency
Do you have sinus issues?
Are you diabetic?
List any areas of arthritis
Do you have epilepsy or seizures?
Do you have osteoporosis?
Do you have high blood pressure?
Do you have claustrophobia?
Do you have varicose veins?
List any conditions being treated by a physician, chiropractor, or therapist
List any current medicantions
List current communicable / contagious diseases
Do you have heart disease?
Do you have asthma or respiratory issues?
List any recent surgeries
List any joint replacements
List any cardiac issues
List any pins, plates, or wires
Current stress level
Current neck or back pain
Current areas of numbness / tingling
Current areas sensitive to touch
List any areas you do not want touched
Do you bruise easily?
List any areas of open wounds / sores
List any significant scars
Other medical conditions we should be aware of
List any sensitivity to lotions / essential oils
Desired results of care
• • •

onpatient Additional Info Medical Form

Chiropractor

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Published: May 21, 2018, 2:35 p.m.
Doctor: Dr. History Physical
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Sunnyvale, CA 94089

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