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Where did you find us?
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Which specialists do you see?
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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COVID-19 Screening Questionnaire
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Please answer Each questions with Yes/No
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Fever of feeling feverish?
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Chills?
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A new cough?
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Shortness of breath?
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A new sore throat?
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New muscle aches?
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New headache?
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New loss of smell or taste?
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CHIROPRACTIC CONSULT QUESTIONNAIRE
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CHIROPRACTIC CONSULT QUESTIONNAIRE
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Chief symptom currently bothering you?
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How long have you had this problem?
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If it was an injury, how did it happen?
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Body Diagram
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Pain Sensitivity
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Please check if you have had any of the following to help you with the pain of your condition
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Other please specify
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Which is the MOST helpful?
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Which of these are you doing CURRENTLY?
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Timing: The pain is
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Quality: How would you best describe the pain?
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Other please specify
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Trend: The pain is
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What activity makes the pain worse?
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What makes the pain better?
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Associated Symptoms: Check any of the symptoms you had recently
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Review of Symptoms: Check any of the following you had recently
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Any family history of
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Social History
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Present Occupation
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Smoking
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Alcohol Consumption
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Caffeine Consumption
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Exercise
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Do you exercise regularly?
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If yes, how many times per week?
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Type of exercise?
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Past Medical History
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Have you had any problems with neck pain in the past?
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Have you had any problems with low back pain in the past?
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Have you had any car accidents that have caused neck or low back injuries?
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Have you had chemical or alcohol dependency treatment in the past?
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Does your primary care physician work at Park Nicollet Clinic?
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Do you have any allergies?
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If yes, please list
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Have you had previous Surgeries or been hospitalized?
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If yes, please explain
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Patient Authorization for Release of Protected Health Information
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Who has the information you want released?
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Hospital / Clinic / Health Care Clinician
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Phone Number
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Fax Number
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Street address
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City
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State
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Zip code
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Where do you want the information sent?
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Person / Business / Hospital / Clinic
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Phone Number
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Fax Number
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Street address
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City
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State
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Zip code
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Information to be sent
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I Want the following Health Records for the date of service mentioned below
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Date of Service
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I want Health Records related to this diagnosis/condition
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I only want individual reports/results mentioned below for these dates of service
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Pick List
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Other please specify
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X-ray/imaging CD (describe)
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Special Permissions
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In compliance with Federal Law, special permission is required to release the following records
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WISOCONSIN RECORDS ONLY: Special permission is required to release the following records
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Purpose for Release
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Other please specify
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Release Method (Pick one)
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Picture ID is required when picking up records, Written
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permission is required if someone other than the patient is
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picking up information
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Date Records Needed (Appointment date)
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Paper
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Electronic
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Turn on this switch for (MAIL)
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Secure Email - Email Address
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Fax - Number
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Pick Up - Date
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Please read through
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