Patient Full Name
Email
Phone
1. Today's problem caused by: (choose from list) - Auto Accident Injury Work Injury Neither
2. Click the box to indicate where you have pain/symptoms:
Other:
3. List Top 3 complaints. Please be specific about the area (ie., left low back, enitre mid back.)
You will have the opportunity to answer the questions 4 - 16 three times, one section for each of your top 3 complaints. Then you'll move on to questions 17 - 30 regarding general health history. Please answer the following questions regarding Complaint #1 ONLY.
4a. How often do you experience your symptoms? - Constantly (76-100% of the time) Frequently (51-75% of the time) Occasionally (26-50% of the time) Intermittently (1-25% of the time)
5a. How would you describe your symptoms?
5a: Please describe "Other"
6a. How are your symptoms changing with time? - Getting Worse Not Changing Getting Better
7a. Using a scale from 1-10 (10 being the worst) please rate this condition: - 0 1 2 3 4 5 6 7 8 9 10
8a. How much has the problem interfered with your work? - Not at all Slightly Moderately Substantially Extremely
9a. How much has the problem interfered with social activities? - Not at all Slightly Moderately Substantially Extremely
10a. Who else have you seen for your symptoms?
10a: Please specify "Other"
11a. How long have you had this problem? (ex. 1 week; 10 years; Too Long To Remember)
12a. How do you think your problem began?
12a: Please specify "Other"
13a. Do you consider the problem to be severe?
14a. What aggravates the problem?
14a: Please specify "Other"
15a. What makes your condition better?
15a: Please specify "Other"
16a. What concerns you the most about your problem; what does it prevent you from?
16a: Please specify "Other"
Please answer questions 4 - 16 regarding Complaint #2 ONLY.
4b. How often do you experience your symptoms? - Constantly (76-100% of the time) Frequently (51-75% of the time) Occasionally (26-50% of the time) Intermittently (1-25% of the time)
5b. How would you describe your symptoms?
5b: Please describe "Other"
6b. How are your symptoms changing with time? - Getting Worse Not Changing Getting Better
7b. Using a scale from 1-10 (10 being the worst) please rate this condition: - 0 1 2 3 4 5 6 7 8 9 10
8b. How much has the problem interfered with your work? - Not at all Slightly Moderately Substantially Extremely
9b. How much has the problem interfered with social activities? - Not at all Slightly Moderately Substantially Extremely
10b. Who else have you seen for your symptoms?
10b: Please specify "Other"
11b. How long have you had this problem? (ex. 1 week; 10 years; Too Long To Remember)
12b. How do you think your problem began?
12b: Please specify "Other"
13b. Do you consider the problem to be severe? - Yes Yes, at times No
14b. What aggravates the problem?
14b: Please specify "Other"
15b. What makes your condition better?
15b: Please specify "Other"
16b. What concerns you the most about your problem; what does it prevent you from?
16b: Please specify "Other"
Please answer questions 4 - 16 regarding Complaint #3 ONLY.
4c. How often do you experience your symptoms? - Constantly (76-100% of the time) Frequently (51-75% of the time) Occasionally (26-50% of the time) Intermittently (1-25% of the time)
5c. How would you describe your symptoms?
5c: Please describe "Other"
6c. How are your symptoms changing with time? - Getting Worse Not Changing Getting Better
7c. Using a scale from 1-10 (10 being the worst) please rate this condition: - 0 1 2 3 4 5 6 7 8 9 10
8c. How much has the problem interfered with your work? - Not at all Slightly Moderately Substantially Extremely
9c. How much has the problem interfered with social activities? - Not at all Slightly Moderately Substantially Extremely
10c. Who else have you seen for your symptoms?
10c: Please specify "Other"
11c. How long have you had this problem? (ex. 1 week; 10 years; Too Long To Remember)
12c. How do you think your problem began?
12c: Please specify "Other"
13c. Do you consider the problem to be severe? - Yes Yes, at times No
14c. What aggravates the problem?
14c: Please specify "Other"
15c. What makes your condition better?
15c: Please specify "Other"
16c. What concerns you the most about your problem; what does it prevent you from?
16c: Please specify "Other"
17. Please fill in - Height:
Weight:
Date of Birth (MM/DD/YYYY):
What is your occupation?
18. How would you rate your overall health? - Excellent Very Good Good Fair Poor
19. What type of exercise do you do? - Strenuous Moderate Light None
20. Please indicate if you have any immediate family members with any of the following conditions:
Please indicate "Other"
21. For each of the symptoms below, check all that apply: Headaches
Neck Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Shoulder Pain
Elbow/Upper Arm Pain
Wrist Pain
Hand Pain
Hip Pain
Upper Leg Pain
Knee Pain
Ankle/Foot Pain
Jaw Pain
Joint Pain/Stiffness
Arthritis
Rheumatioid Arthritis
Cancer
Tumor
Asthma
Chronic Sinusitis
High Blood Pressure
Heart Attack
Chest Pains
Stroke
Angina
Kidney Stones
Kidney Disorders
Bladder Infection
Painful Urination
Loss of Bladder Control
Prostate Problem
Abnormal Weight Gain/Loss
Loss of Apetite
Abdominal Pain
Ulcer
Hepatitis
Liver/Gall Bladder Disorder
General Fatigue
Muscular Incoordination
Visual Disturbances
Dizziness
Diabetes
Excessive Thirst
Frequent Urination
Smoking/Tobacco Use
Drug/Alcohol Dependence
Allergies
Depression
Systemic Lupus
Epilepsy
Skin Problems/Eczema
HIV/AIDS
Hormonal Replacement
(Women Only) Birth Control Pills
(Women Only) Pregnancy
22. Please list all prescription and OTC medications you are currently taking:
23. Please list all of the supplements/vitamins you are currently taking:
24. Please list all surgical procedures you have had:
25. Please list activities you do at work, then please choose frequency from drop down lists below.
Sit - Most of the day Half of the day A little of the day None of the day
Stand - Most of the day Half of the day A little of the day None of the day
Computer work - Most of the day Half of the day A little of the day None of the day
On the phone - Most of the day Half of the day A little of the day None of the day
Perform Manual Labor - Most of the day Half of the day A little of the day None of the day
Read - Most of the day Half of the day A little of the day None of the day
Travel - Most of the day Half of the day A little of the day None of the day
Other - Most of the day Half of the day A little of the day None of the day
26. What activities do you do outside of work?
27. Have you ever been hospitalized?
If yes, Why?:
28. Have you ever been to a chiropractor before?
28b. How long have you had this problem? (ex. 1 week; 10 years; Too Long To Remember)
29. Have you had significant past trauma (Auto/Bike/Auto Accidents, Falls, Loss of Consciousness, etc.)?
If yes, please describe:
30. Anything else pertinent to your visit today?
31. Have you had any X-rays/CTs/MRIs in the last 5 yrs? If so, please list the study, when and where they were taken. If you have other studies or related Neurology/Orthopedic reports, plese list them here and bring them to your first visit, if possible.
32. Are you interested in information about: