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Intake
Please complete this questionnaire. Your answers will help us determine if we can help you. If we do not sincerely believe your condition will respond satisfactory, we will not accept your case. THANK YOU
Email address *
Name:
Your answer
Gender
Marital Status
other
Your answer
Age
Your answer
Date of Birth
MM
/
DD
/
YYYY
Social Security Number
Your answer
Home Address
Your answer
Phone Number
Your answer
Email Address
Your answer
Employers Address
Your answer
Work Number
Your answer
Occupation
Your answer
How did you hear about us?
Your answer
Contact Information
Name
Your answer
Address
Your answer
Relationship
Your answer
Phone Number
Your answer
Reason For Visit Today (check all that apply)
A. MAJOR COMPLAINTS
1. What are your major complaints?
Shoulder Pain
Shoulder Numbness
Shoulder Tingling
Arm Pain
Arm Numbness
Arm Tingling
Forearm Pain
Forearm Numbness
Forearm Tingling
Hand Pain
Hand Numbness
Hand Tingling
Buttock Pain
Buttock Numbness
Buttock Tingling
Hip Pain
Hip Numbness
Hip Tingling
Thigh Pain
Thigh Numbness
Thigh Tingling
Leg Pain
Leg Numbness
Leg Tingling
Foot Pain
Foot Numbness
Foot Tingling
2. Date problems began
Your answer
3. Describe how problems began (fall, lifting, etc)
Your answer
4. Current pain level
No pain
Unbearable pain
5. How often do you experience symptoms
6. Are your symptoms worse in the
7. Since it began is it
8. What makes symptoms better
Your answer
9. What makes symptoms worse
Your answer
10. What daily activities are being affected
Your answer
11. Prior care/treatments for current complaints
Your answer
B. REVIEW OF SYSTEMS
Are you presently suffering (or within the past 6 months suffered) from any of the following?
1. A. General
Other
Your answer
2. What are your habits?
Never
Occasionally
Moderately
Excessively
Smoking
Alcohol
Recreational Drugs
Exercise
Stress
Poor Diet
C. MEDICAL HISTORY
1. A. Have you been to a chiropractor?
B. Do you have a family physician?
C. (Women) To the best of your knowledge are you pregnant?
(Women) Are you under the regular care of an OB-GYN?
D. Have you been hospitalized in the last 5 years?
E. Are you currently taking any medications?
If yes, which of the following
Other
Your answer
2. Which of the following illness have you had?
Other
Your answer
3. Prior injury history
Other
Your answer
4. Fractures/Broken bones (location & year)
Your answer
5. Surgery (location & year)
Your answer
D. FAMILY HISTORY
Cancer
Diabetes
Heart Trouble
High Blood Pressure
Stroke
Multiple Sclerosis
Headaches
Neck Problems
Back Problems
Disc Problems
Joint Problems
Arthritis
Pinched Nerve
Osteoporosis
Scoliosis
Bad Posture
E. INSURANCE INFORMATION
1. Is your condition due to an automobile accident?
Date of accident
MM
/
DD
/
YYYY
Have you filed an accident report?
2. Is your condition due to a job injury?
Date of injury
MM
/
DD
/
YYYY
Have you filed an injury report?
3. Do you have health insurance?
Company
Your answer
Policy and/or Group number
Your answer
4. Are you covered by Medicare?
If yes, Medicare Number
Your answer
Insurance Understanding
I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable.
F. PAYMENT POLICY
Payment is required at the At Time of Service unless prior arrangements are made.
I acknowledge that typing my name below will be considered as my signature since forms are submitted electronically.
Signature
Your answer
MM
/
DD
/
YYYY
FUNCTIONAL RATING INDEX
AREA OF COMPLAINT
1. Pain Intensity
No pain
Worst possible pain
2. Sleeping
Perfect sleep
Totally disturbed sleep
3. Personal Care (washing, dressing, etc.)
No pain; no restrictions
Severe pain; 100% assistance
4. Travel (driving, etc.)
No pain on long trips
Sever pain on short trips
5. Work
Can do usual work
Cannot work
6. Recreation
Can do all activities
Cannot do any activities
7. Frequency of Pain
No pain
Constant pain; 100% of the day
8. Lifting
No pain with heavy weight
Increased pain with any weights
9. Walking
No pain; any distance
Increased pain with all walking
10. Standing
No pain after several hours
Increase pain with any standing
I acknowledge that typing my name below will be considered as my signature since forms are submitted electronically.
Signature
Your answer
MM
/
DD
/
YYYY
Submit
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