Medical History Intake
Though some questions are not required,  in order to get a complete medical history,  please answer questions  if they apply to your personal medical history.  During review with your doctor, any questions about the form will can be answered. . A complete medical history will provide valuable documentation to tie in or rule out seemingly unrelated medical history.  This form intentionally does not contain personal identifiable information.    Only upon provider's review, will it be updated with that information
Sign in to Google to save your progress. Learn more
Please enter the DATE and TIME of your appointment so that we may locate your completed form.   *
Person completing this form *
CHIEF COMPLAINT -What is your complaint or why are you seeking chiropractic care? *
ONSET -  How long have you had this condition? *
TIMING *
When did this begin? *
PALLIATIVE- What activities/treatments improve the condition? *
Required
CAUSE -What caused the condition or what circumstance preceded the symptoms? *
OTHER TREATMENT- Have you been treated or treated yourself for this condition.   *
Required
If you have ever had this condition before, please describe the timing a circumstances. *
Symptoms radiating to or affecting the extremities. 
Upper extremities include shoulders, arms, elbows, forearms, wrists and fingers.      Lower extremities include hip, thighs, knee, leg, ankles, feet and toes.
EXTREMITIES -   Do you have any symptoms that seem to radiate to your *
Required
Do you have incontinence (loss of bowel or bladder control)? *
Required
What is the extreme LEVEL of your condition be it pain or discomfort, if 10 is the worst? *
BETTER
WORSE
What is the FREQUENCY of your symptoms? *
PROVOCATIVE -What activities increase the condition? *
Required
PROVOCATIVE OTHER - Are there any activities not listed above the exacerbate your symptoms?
QUALITY -How does it feel? *
Required
Do you describe your pain in a different way than listed above?
If you have other complaints or concerns you may discuss them here.
Rx/SUPPLEMENTS -Please list any medications and supplements/vitamins that  you are taking. *
How much alcohol do you consume? *
What is your SMOKING-(if currently smoking please indicate the number of cigarettes or cigars)? *
What is. your OCCUPATION?   *
What is your EXERCISE regimen? *
Required
If your physical activity was not listed, please describe it here.
PAST MEDICAL HISTORY *
Required
PROCEDURES/SURGERIES/OTHER CONDITIONS - Do you have any history of other conditions/surgeries/procedures not listed above?  please list dates. You may give a document with this information at the time of your appointment. *
FAMILY Medical history- *
Required
Do you have a PACEMAKER or any other electrical device. *
Are you PREGNANT or attempting to become pregnant *
CONSTITUTIONAL-Do you have or have you had? *
Required
MUSCULOSKELETAL- Mark any symptoms you may have.  *
Required
NEUROLOGICAL- Mark any symptoms you may have. *
Required
ACTIVITIES OF DAILY LIVING - Which are affected by your condition. *
Required
Are there any other activities affected by your condition?
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms