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Are you a New Patient?
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If NOT, when was the last time in the office?
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How did you hear about us?
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Who Referred you?
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Occupation
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Chiropractic Intake Form
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Regenerative Medicine
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Medical Intake Form
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Section 1: How Can We Help?
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What is the primary reason for your visit?
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What are your primary goals?
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Any specific goals? I want to be able to
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Additional goals you are interested in?
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Section 2: Tell us About your Primary Issue
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How long ago did it begin?
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Was this a result of a car accident or accident at work?
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If not, was there a known cause?
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Is there anything that makes it better?
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Is there anything that makes it worse?
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Other
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Have you seen other practitioners for this?
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Do you have X-Rays/MRI's of this condition?
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Does the discomfort refer / travel anyplace else?
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where?
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How intense is the discomfort? (check multiple if it varies)
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How often do you feel it?
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hours per day
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days per week
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days per month
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When was the last time you felt good?
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Section 3: About Your Health
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Height:
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Weight:
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Blood pressure (if known):
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Current pregnancy or breast feeding
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Alcohol usage
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day/week/mo
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Tobacco usage
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day/week/mo
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Current medications or treatments:
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ALL known allergies, drug or common:
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Past surgeries and approximate dates:
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History of major trauma or illness:
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Current or past issues with the following body systems:
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Eyes
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Please describe
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Ears
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Please describe
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Nose
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Please describe
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Throat
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Please describe
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Skin
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Please describe
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Hair
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Please describe
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Nails
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Please describe
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Bones
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Please describe
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Joint
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Please describe
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Heart
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Please describe
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Lung
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Please describe
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Digestive system
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Please describe
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Nervous system
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Please describe
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Vascular system
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Please describe
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Respiratory system
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Please describe
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Urinary system
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Please describe
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Endocrine system
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Please describe
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Reproductive system
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Please describe
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Diabetes
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Please describe
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Neuropathy
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Please describe
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Osteoporosis/penia
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Please describe
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