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Your Complaint Today
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Follow-Up Intake Questions
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How did you hear about us?
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Primary Complaint
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Current pain level today
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Pain level at its worst
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Pain level at its best
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Current duration of pain
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If certain motions, which motions?
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If intermittent, how often?
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Your pain is best described as (Select all that apply):
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This pain is made worse/affected by:
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If other, specify
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What relieves your symptoms? (Select all that apply)
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If other, specify
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How limiting is your pain?
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Limitations
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Personal Care
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Social Life
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Lifting/Exercising
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Traveling
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Walking
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Working
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Sitting
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Standing
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Anything new regarding your pain that you would like us to know:
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If so, what?
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Indicate the location of your pain (in clinic check-in only):
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Past Medical/ Family/ Social History
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Past Medical History
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Past Medical History Freewrite
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Past Surgical History
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Past Surgical History Freewrite
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Family History
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Mother's Medical History
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Father's Medical History
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Sibling(s)' Medical History
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Children(s)' Medical History
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Social History
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Marital Status
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Occupation
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Drug Use
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Alcohol Use
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Tobacco Use
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Medical Marijuana Card
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Other Information
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Who may we thank for referring you
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Where did you find us?
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Are you currently
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Which specialists do you see?
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Want access to online portal?
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Do you use online scheduling?
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Pharmacy Information
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Pharmacy Information
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Pharmacy Name
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If other, specify
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Pharmacy Crossroads
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Personal Injury/Accident
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Personal/Accident Injury (Please toggle if yes)
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Have you retained an attorney?
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Your Attorney’s Name
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Attorney’s Phone
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Your Attorney’s Address
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City/State
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Zip Code
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ACCIDENT INFORMATION
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Date of Accident
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Time of Accident (Specify AM/PM)
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Your Vehicle - Year
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Make
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Model
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Other Vehicle - Year
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Make
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Model
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Where you wearing a seatbelt?
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Accident Type
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Damage to Your Vehicle
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Other Vehicle Damage
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Describe the Accident
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ACCIDENT SPECIFICS
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Was this injury accident related?
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Auto
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Work
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Other
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Was this a Job or Work related injury?
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Were you the
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If passenger, where were you sitting
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Did the airbags deploy
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Impending Collision, were you
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Did you head
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Others, please specify
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Did your experience
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Others, please specify
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What were the Weather Conditions?
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The Road was
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Time of Day
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State your emotions and physical state immediately following the accident
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State your emotions and physical state after the first few days
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IMMEDIATELY FOLLOWING THE ACCIDENT
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PAIN ASSESSMENT
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Pain Assessment
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Level of Pain
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When and how did you pain/problem start? Please explain in detail
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Pain Diagram
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Past Treatment
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Previous Treatments
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Physical Therapy
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Duration (ex. 1 week, 1 month)
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Please select from the following
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Chiropractor
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Duration (ex. 1 week, 1 month)
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Please select from the following
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Injections
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Duration (ex. 1 week, 1 month)
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Please select from the following
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NSAIDS (Anti-Inflammatories)
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Duration (ex. 1 week, 1 month)
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Please select from the following
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Opiate (Pain) Medication
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Duration (ex. 1 week, 1 month)
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Please select from the following
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Past Imaging
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Previous Imaging
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X-Ray - Date(s)
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Facility/Office Performed
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Location on body (ex-Neck, Back, Thoracic Spine)
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MRI scan - Date(s)
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Facility/Office Performed
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Location on body (ex-Neck, Back, Thoracic Spine)
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CT scan - Date(s)
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Facility/Office Performed
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Location on body (ex-Neck, Back, Thoracic Spine)
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Secondary Complaint
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Secondary Complaint
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Follow-Up Intake Questions - 2nd
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Secondary Complaint
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Current pain level today
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Pain level at its worst
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Pain level at its best
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Current duration of pain
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If certain motions, which motions?
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If intermittent, how often?
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Your pain is best described as (Select all that apply):
• • •
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This pain is made worse/affected by:
• • •
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If other, specify
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What relieves your symptoms? (Select all that apply)
• • •
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If other, specify
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How limiting is your pain?
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Limitations - 2nd
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Personal Care
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Social Life
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Lifting/Exercising
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Traveling
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Walking
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Working
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Sitting
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Standing
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Anything new regarding your pain that you would like us to know:
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If so, what?
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Third Complaint
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Third Complaint
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Follow-Up Intake Questions - 3rd
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Third Complaint
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Current pain level today
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Pain level at its worst
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Pain level at its best
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Current duration of pain
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If certain motions, which motions?
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If intermittent, how often?
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Your pain is best described as (Select all that apply):
• • •
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This pain is made worse/affected by:
• • •
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If other, specify
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What relieves your symptoms? (Select all that apply)
• • •
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If other, specify
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How limiting is your pain?
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Limitations - 3rd
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Personal Care
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Social Life
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Lifting/Exercising
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Traveling
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Walking
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Working
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Sitting
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Standing
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Anything new regarding your pain that you would like us to know:
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If so, what?
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Weight Loss Questionnaire
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Do you or anyone in your family have a history of thyroid cancer?
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Do you take medications for any of these conditions?
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New Switch
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New Yes / No
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