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SUBJECTIVE COMPLAINTS
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Please select any of the following you are experiencing...
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Spine / Core
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All WNL (I do not have any Spinal Complaints)
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Left Neck Pain
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Right Neck Pain
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Left Mid Back Pain
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Right Mid Back Pain
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Left Low Back Pain
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Right Low Back Pain
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Left Pelvic pain
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Right Pelvic pain
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Left Chest / Rib Pain
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Right Chest / Rib Pain
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Left Jaw Pain
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Right Jaw Pain
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Left Face Pain
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Right Face Pain
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Upper Extremity
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All WNL (I do not have any Upper Extremity Complaints)
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Left Shoulder Pain
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Right Shoulder Pain
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Left Upper Arm Pain
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Right Upper Arm Pain
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Left Elbow Pain
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Right Elbow Pain
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Left Forearm Pain
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Right Forearm Pain
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Left Wrist Pain
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Right Wrist Pain
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Left Hand Pain
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Right Hand Pain
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Left Finger / Thumb Pain
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Right Finger / Thumb Pain
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Numbness / Tingling in Arms / Hands
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Loss of Strength in Arms / Hands
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Lower Extremity
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All WNL (I do not have any Lower Extremity Complaints)
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Left Hip Pain
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Right Hip Pain
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Left Upper Leg / Thigh Pain
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Right Upper Leg / Thigh Pain
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Left Knee Pain
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Right Knee Pain
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Left Lower Leg Pain
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Right Lower Leg Pain
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Left Ankle Pain
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Right Ankle Pain
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Left Foot Pain
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Right Foot Pain
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Left Toe Pain
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Right Toe Pain
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Numbness / Tingling in Legs / Feet
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Loss of Strength in Legs / Feet
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Headaches
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I am NOT currently suffering from Headaches
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I am suffering from Headaches
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On a Scale of 1-10 (10 being the worst) the pain is...
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The pain frequency is...
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Select any associated symptoms
• • •
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I would describe my headaches as...
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Acute (new) Non-Traumatic
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Chronic (6 weeks or more) Non-Traumatic
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Acute (new) Traumatic
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Chronic (6 weeks or more) Traumatic
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Migraine with Aura (flash of light, blind spots, light sensitivity)
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Migraine without Aura
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PLEASE PROVIDE US WITH SOME MORE DETAIL ABOUT YOUR INJURIES...
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Spinal Complaints
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Here you can list up to 3 Spinal complaints you are experiencing
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All WNL (I have no Spinal Complaints)
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Spinal Complaint #1
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Spinal Complaint #1
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On a scale of 1-10 (10 being the worst) how would you describe the pain?
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The pain frequency is
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How would you classify the pain?
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The pain type is...
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Does the pain radiate?
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If YES - Where?
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Spinal Complaint #2
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Spinal Complaint #2
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On a scale of 1-10 (10 being the worst) how would you describe the pain?
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The pain frequency is
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How would you classify the pain?
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The pain type is...
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Does the pain radiate?
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If YES - Where?
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Spinal Complaint #3
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Spinal Complaint #3
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On a scale of 1-10 (10 being the worst) how would you describe the pain?
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The pain frequency is
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How would you classify the pain?
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The pain type is...
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Does the pain radiate?
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If YES - Where?
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Extremity Complaints
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Here you can list up to 2 Extremity complaints you are experiencing
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All WNL (I have no Extremity Complaints)
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Extremity Complaint #1
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Extremity Complaint #1
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The pain is located on the
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On a scale of 1-10 (10 being the worst) how would you describe the pain?
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The pain frequency is
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How would you classify the pain?
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The pain type is...
• • •
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Extremity Complaint #2
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Extremity Complaint #2
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The pain is located on the
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On a scale of 1-10 (10 being the worst) how would you describe the pain?
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The pain frequency is
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How would you classify the pain?
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The pain type is...
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Other Complaints
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If you could not find a section above to describe your pain, please describe here...
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Other Complaint #1
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Other Complaint #1
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The pain is located on the
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On a scale of 1-10 (10 being the worst) how would you describe the pain?
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The pain frequency is
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How would you classify the pain?
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The pain type is...
• • •
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NEUROLOGICAL COMPLAINTS
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Please select if you are CURRENTLY experiencing...
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All WNL (I have none of these)
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Dizziness
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Nausea
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Fatigue
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Nervousness
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Insomnia (lack of sleep)
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Loss of Memory
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Light Sensitivity
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Loss of Smell
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Irritability
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Sleeping Problems
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Shortness of Breath
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Difficulty Swallowing
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Loss of Balance
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Ringing in Ears
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Clumsiness
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Constipation
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Diarrhea
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Fainting
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Cold Sweats
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Loss of Taste
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Reduced Appetite
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Loss of Bladder / Bowel Control
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CONSTITUTIONAL COMPLAINTS
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Please select if you are CURRENTLY experiencing or HAVE EVER experienced
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All WNL (I have none of these)
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Heart Problems
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Diabetes
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Cancer
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Stroke
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High Blood Pressure
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Thyroid Problems
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Tuberculosis
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Prostate Disorder
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Female Problems
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Urinary Problems
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Kidney Problems
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Asthma
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Ulcers
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Seizures
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Nose Bleeds
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Chest Pains
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Allergies
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Osteoporosis
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Hypoglycemia
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Digestive Disorders
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Skin Conditions
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Other
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Please describe any of the previous you selected
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Please describe any pertinent FAMILY MEDICAL HISTORY:
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-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*-----*
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THIS BOTTOM SECTION IS FOR A CAR ACCIDENT OR SLIP AND FALL INJURY ONLY
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***If this does not apply to you, your intake process is complete***
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***If you have not yet obtained legal representation please discuss this with the doctor***
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I AM HERE BECAUSE OF A CAR ACCIDENT
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I AM HERE BECAUSE OF A SLIP AND FALL OR OTHER TYPE OF INJURY
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What was the date of the accident? MM/DD/YY
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What was the date of the accident? MM/DD/YY
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I went to a hospital / urgent care / other health care provider for this accident prior to today's visit
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I went to a hospital / urgent care / other health care provider for this accident prior to today's visit
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I was taken by Ambulance or EMS to the hospital
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I was taken by Ambulance or EMS to the hospital
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If Yes - Please list what facility / doctor you went to
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If Yes - Please list what facility / doctor you went to
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I received X-rays / CT scan / MRI / or other type of imaging after this accident
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I received X-rays / CT scan / MRI / or other type of imaging after this accident
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If Yes - Please describe the type of imaging and body areas
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If Yes - Please describe the type of imaging and body areas
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I was prescribed medications or have been taking medications after this accident
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I was prescribed medications or have been taking medications after this accident
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If Yes - Please list the medications
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If Yes - Please list the medications
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Select your position in the vehicle
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I experienced head trauma due to this accident
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Type of Impact
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I experienced Loss of Consciousness due to this accident
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Select where the accident happened
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Please describe what happened during your accident
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I experienced head trauma due to this accident
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I experienced Loss of Consciousness due to this accident
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Did the airbags deploy?
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Did your body hit anything in the car?
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If Yes - Please state which body part and what it impacted; Ex: Left Shoulder hit the window
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