Adult Intake Form

How may I be of Service?

Thank you for taking the time to complete this detailed secure form. I consider a person's whole health picture and include physical, emotional and chemical stresses, and health and life history when determining how I can best be of service to you at this time.

978-381-1916
drnicole@drnicoleas.com

Today's Date

DEMOGRAPHIC INFORMATION

Contact Information

First name

Last name

Greeting (Preferred name, nickname, pronoun)

Street Address (include apartment, floor, unit, etc)

City

State

Zip Code

Cell phone number

Home phone number

Work phone number

Email address

Date of birth

Age

Gender (Biological and Actual)

Occupation

Employer

If retired, what was your occupation?

Travel time to this office

Referred to our office by:

Name of person responsible for payment of professional services (if not an existing patient, please include name, address, cell phone number and email)

Family Information

Name and occupation of spouse/partner

Names and ages of children

Other household members (include extended family, non-family and pets)

Emergency Contact

Add another emergency contact

Primary Care Physician

First name

Last name

Phone number

Secure email address

Address

CURRENT HEALTH REPORT

What are your long-term goals in coming other this office?

How long has it been since you have felt well?

Are you pregnant?

Yes No Not sure

If yes, how many weeks?

If yes, name and contact info for your birth team (OB, midwife, doula, etc.)

Please describe the principal health concerns for which you would like to come to this office.

Are your complaints due to an injury?

Yes

Auto accident

Workplace injury

Are any of your concerns interfering with

Work

Sleep

Sports

Parenting

Daily routine

Have you lost days from work? If yes, include dates.

Mark the areas on the image where you are experiencing any symptoms. There will be room in the sections below to further describe each area of concern. Ignore the numbers, just mark the locations of concerns. Please pay attention to left/right, front/back locations.

Below there is space to describe 3 primary health concerns in detail.

Additional space is provided after three main sections for any additional concerns.

If you do not have a #2 or #3 concern, you may skip that section

HEALTH CONCERN #1

Describe the #1 reason you are seeking chiropractic treatment.

Was there a known injury or cause of onset of this condition? If yes, describe

When did the symptoms start? (approximate month/year if exact date unknown)

Have you experienced these types of symptoms before?

Yes No

This symptom is (check all that apply)

Constant

Comes and goes

Daily

Weekly

Monthly

More than monthly but less than yearly

The symptom is:

Getting better on it's own or with another intervention Staying the same/plateaued Getting worse

If other, please explain:

How long do symptoms generally last? (seconds, minutes, hours, days, weeks etc)

What causes symptoms or aggravates symptoms (positions, activities, motions etc)

What brings relief of symptoms? (Stretching, lying flat, knees to chest, icing, heating, meds etc)

Are symptoms better or worse at any time of day, time of month, time of year/season? (Examples:1st thing in the morning, end of day, 3pm, 2am, beginning of work week, monthly with hormonal cycle, specific seasons or holidays, birthdays or anniversaries)

Other treatments you have had for this symptom (Pain doctor, orthopedist, neurologist, other MD, PT, acupuncture, chiropractic, osteopathic, massage, reiki, Craniosacral etc). *With who and where? *Past or current? *Successful or not helpful? List any diagnosis given and describe treatment.

HEALTH CONCERN #2

Describe the #2 reason you are seeking chiropractic treatment.

Was there a known injury or cause of onset of this condition? If yes, describe

When did the symptoms start? (approximate month/year if exact date unknown)

Have you experienced these types of symptoms before?

Yes No

This symptom is (check all that apply)

Constant

Comes and goes

Daily

Weekly

Monthly

More than monthly but less than yearly

The symptom is:

Getting better on it's own or with another intervention Staying the same/plateaued Getting worse

If other, please explain:

How long do symptoms generally last? (seconds, minutes, hours, days, weeks etc)

What causes symptoms or aggravates symptoms (positions, activities, motions etc)

What brings relief of symptoms? (Stretching, lying flat, knees to chest, icing, heating, meds etc)

HEALTH CONCERN #3

Describe the #3 reason you are seeking chiropractic treatment.

Was there a known injury or cause of onset of this condition? If yes, describe

When did the symptoms start? (approximate month/year if exact date unknown)

Have you experienced these types of symptoms before?

Yes No

This symptom is (check all that apply)

Constant

Comes and goes

Daily

Weekly

Monthly

More than monthly but less than yearly

The symptom is:

Getting better on it's own or with another intervention Staying the same/plateaued Getting worse

If other, please explain:

How long do symptoms generally last? (seconds, minutes, hours, days, weeks etc)

What causes symptoms or aggravates symptoms (positions, activities, motions etc)

What brings relief of symptoms? (Stretching, lying flat, knees to chest, icing, heating, meds etc)

ADDITIONAL HEALTH CONCERNS

Has anyone in your family had similar conditions? If yes, please explain.

MEDICAL HISTORY

Current height and weight (in feet, inches and pounds)

Lowest adult weight, highest adult weight and desired weight

Do you wear (check all that apply)

Dental night guard

Dental splint

Glasses

Hearing aids

Heel lift(s)

Orthotics

Other

Describe other

Did you/do you wear braces/Invisalign or use a palate expander? Include dates

Have you been treated for any other medical condition by a physician in the past year? if yes, please explain

What PRESCRIPTION medications are you taking (if any) and for what conditions? Please list/explain.

What NON-PRESCRIPTION pain relievers are you taking (if any) and for what conditions? How many per day? (include Advil, Alleve, Ibuprofen, Excedrin, Tylenol, etc). Please list/explain.

Other NON-PRESCRIPTION medications are you taking (if any) and for what conditions? (include laxatives, antihistamines, decongestants, stimulants, etc). Please list/explain.

Current vitamins, supplements and herbs you are taking, Please list/explain.

ALLERGIES or SENSITIVITIES to drugs, foods, pollens, chemicals, animals, etc. Please list/explain.

Have you been on frequent or prolonged ANTIBIOTIC therapy (such as erythromycin, penicillin, tetracycline, amoxicillin) or CORTICOSTEROID therapy (such as prednisone (Rayos), methylprednisolone (Medrol), dexamethasone (Decadron), triamcinolone (Kenalog), prednisolone, and hydrocortisone (Cortef))? Please list/explain.

Have you had chemotherapy or radiation? If so for what and when? Is there ongoing maintenance treatment?

INJURY/ILLNESS HISTORY

Please list major accidents, serious falls, or injuries with dates.

Cranial injuries, concussions, losses of consciousness. Please list dates and symptoms, how long symptoms lasted

Have you had any past fractures, sprains, or breaks? If so, include the type of injury, location on your body, and when the injury occurred.

Major dental work (Like extractions, root canals, bone grafts, etc. Please list where in mouth, when and what)

Please list with dates all SURGERIES (including where and on what side of body if applicable), and all HOSPITALIZATIONS with dates.

List with dates all X-rays or special imaging (CT scans, PET scans, ultrasounds, MRIs) in the last 10 years

Is there anything else regarding your medical history that we should be aware of?

HABITS OF DAILY LIVING

List favorite hobbies or other life interests

Frequency of exercise

<1 time per week

1-3 times per week

4-5 times per week

6-7+ times per week

Type of exercise

None Moderate Heavy

Work activity (check all that apply)

Sitting

Standing

Walking

Light labor

Heavy labor

How are your stress levels?

High Moderate Low

Stress reduction or relaxation activities (like meditation, breath work, yoga, prayer, etc.)

Are you currently on any psychotropic medication or receiving psychological counseling? Please describe

Sleep habits

Hours of sleep per night, sleep quality (check all that apply)

7-8+

5-6

3-4

0-2

Restful

Restless

I do dream

I do not dream

What time do you go to bed?

Do you smoke?

Regularly Occasionally No Quit

Do you drink alcohol?

Regularly Occasionally No I have felt the need to cut down on my drinking

Non-medical drug use-type and frequency (stimulants, depressants, hallucinogens, inhalants)

Do you have amalgam dental fillings

Yes No

Diet

Do you have a healthy and balanced diet?

Regularly Occasionally No

Do you eat regular meals?

Yes No

Do you sit down for meals?

Yes No

Do you eat or drink between meals?

Yes No

If yes, what?

How often does your diet consist mainly of salads, whole grains, eggs, fresh fruits and vegetables, lean meats, beans or legumes?

Almost always Often Sometimes Rarely

Do you eat processed foods with artificial colorings, flavorings, preservatives like bologna, sausage, cheese spreads, baked goods?

Almost always Often Sometimes Rarely

Do you eat "fast food"?

Almost always Often Sometimes Rarely

Do you add sugar to coffee, tea, cereals, or other foods?

Yes No

Do you use artificial sweeteners?

Yes No

How many servings per day of:

Do you drink tap, filtered or reverse-osmosis water? Please state which. If reverse osmosis, do you replace minerals?

Preferred diet (Keto, paleo, vegan, vegetarian, pescatarian, Mediterranean, etc.)

GENERAL HEALTH HISTORY

Other:

Have you lived or traveled outside of the United States?

Yes No

Have you had traveler's diarrhea?

Yes No

Have you been tested for intestinal parasites?

Yes No

Have you been treated for intestinal parasites?

Yes No

If yes, please describe when and what parasite(s)

CHILDHOOD HISTORY

Were you adopted? If so, at what age?

Were you breast or bottle fed? For how long?

Were you born vaginally or c-section?

Known complications? (Include forceps or vacuum delivery, dystocia, low APGAR, etc)

Describe other:

FAMILY HISTORY

Do any of your family members below have:

Diabetes (write D)

Heart Disease or High Blood Pressure (write H)

Cancer (write C and diagnosis)

Musculoskeletal problems (write M and diagnosis)

Other (Describe)

Grandparents

Mother

Father

Siblings

Age of biological parents. If deceased, age and cause

Number of siblings, age and health status

REVIEW OF SYSTEMS

Please check the box if you have history of any of the listed conditions

THYROID

Overactive

Underactive

Enlarged

SKIN

Boils

Bruise easily

Dryness

Eczema

Psoriasis

Hives or allergies

Itching

Sensitive skin

Skin eruptions

RESPIRATORY

Asthma

Chest pain

Chronic cough

Difficulty breathing

Spitting blood

Spitting phlegm

Wheezing

Last Pap date

Menstrual cycle length

Date of last period

Your full completion of this intake form will help me determine whether my services might meet your needs. Upon my review of this form, I will contact you to set up an initial appointment as a new patient, or, if I believe that my services may not meet your needs, to schedule a phone or video consultation if you would like suggestions for where you might next seek care in our challenging US health care and insurance system.

PLEASE NOTE: Because many of our patients (and I myself) have allergies to artificial fragrances we ask you not to wear scented products or clothing washed in heavily scented detergent or dried with dryer sheets. These include perfumes, hair products, aftershaves, deodorants and lotions whose ingredients include "fragrance" or "perfume" and scented laundry products like Tide Pods, Gain and Bounce. Clothes and items can also be an issue after exposure to chemical air fresheners like Febreeze and Plug in's so please alert us in advance if you find yourself in an uber or taxi using one immediately before your visit.

It bears noting that these chemicals are very bad for health. They are absorbed through the skin and respiratory systems and they disrupt hormones and the nervous system. If your are using these kinds of products and seeking a healthier lifestyle, please consider changing to unscented products or products scented with natural substances.

I undersand and will abide by the "No Fragrance Policy" at 63 Middle Street

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