Medical History Intake
Though some questions are not required, to get a complete medical history, please answer them if they apply. This will allow us to get a complete medical history documented for review before your evaluation. It will save time during your visit.
Email address *
Date and Time of your appointment *
Your answer
Person completing this form *
CHIEF COMPLAINT -What is your complaint or why are you seeking chiropractic care? *
Your answer
ONSET - How long have you had this condition? *
Your answer
CAUSE -What caused the condition or what circumstance preceded the symptoms? *
Your answer
OTHER TREATMENT- Have you been treated or treated yourself for this condition. *
Your answer
If you have ever had this condition before, please describe it. *
Your answer
Upper extremities includes shoulders, arms, elbows, forearms, wrists and fingers. Lower extremities includes 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? *
Do you have bowel or bladder dysfunction? *
What is the LEVEL of pain/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?
Your answer
PALLIATIVE -What activities decrease the condition? *
Required
PALLIATIVE OTHER -Is there anything not listed above that decreases your symptoms?
Your answer
QUALITY -How does it feel? *
Required
Do you describe your pain in a different way than listed above?
Your answer
If you have other complaints or concerns you may discuss them here.
Your answer
Rx/SUPPLEMENTS -Please list any medications and supplements/vitamins that you are taking. *
Your answer
How much alcohol do you consume? *
Your answer
What is your SMOKING-(if currently smoking please indicate the number of cigarettes or cigars)? *
Your answer
What is. your OCCUPATION? *
Your answer
What is your EXERCISE regimen? *
Required
If your physical activity was not listed, please describe it here.
Your answer
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. *
Your answer
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 *
Required
NEUROLOGICAL *
Required
ACTIVITIES OF DAILY LIVING - Which are affected by your condition. *
Required
Are there any other activities effected by your condition?
Your answer
Is there any more information that you would like to provide, please do so here.
Your answer
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