New Patient Form

Marcella Brechler, DC Taylor Hoskins, DC Craig Brechler, PT

Please correct the errors described below.
Address, City, State, Zip
For Confirming Appointment
Other please fill out next section
Address, City, State, Zip

  • The rating scale below is designed to measure the degree to which several aspects of your life are presently disrupted by your heath condition (pain and/or symptoms you may be experiencing). In other words, we would like to know how much your health condition (pain and/or symptoms you may be experiencing)is preventing you from doing what you would normally do, or from doing it as well as you normally would. Respond to each category by indicating the overall impact of pain in your life, not just when the pain is worst.
  • For each of the six categories of daily living listed, PLEASE INDICATE THE NUMBER WHICH BEST DESCRIBES YOUR TYPICAL LEVEL OF ACTIVITIES.
  • 0 means NO DISABILITY AT ALL, and a score of 10 means that ALL OF THE ACTIVITIES IN WHICH YOU WOULD NORMALLY BE INVOLVED HAVE BEEN TOTALLY DISRUPTED or prevented by your heath condition (pain and/or symptoms you may be experiencing).

1. FAMILY/HOME RESPONSIBILITIES: activities related to the home or family including chores and duties performed around the house (yard work, doing dishes, errands, favors for other family members, driving children to school, etc).

0-10

2. RECREATION: hobbies, sports, and other similar leisure time activities.

0-10

3. SOCIAL ACTIVITY: activities which involve participation with friends and acquaintances other than family members including parties, theater, concerts, dining out, and other social functions.

0-10

4. OCCUPATION: activities that are a part of or directly related to one's job including nonpaying jobs as well, such as that of a homemaker or volunteer worker.

0-10

5. SELF CARE: activities which involve personal maintenance and independent daily living (taking a shower, driving, getting dressed, etc).

0-10

6. LIFE SUPPORT ACTIVITY: basic life supporting behaviors such as eating, sleeping, and breathing.

0-10

NOTICE: NOT ALL PATIENTS REQUIRE X-RAYS TO DETERMINE TYPE OF CARE AND LENGTH OF CARE. IF YOUR EXAMINATION WARRANTS X-RATS ANALYSIS, THE FOLLOWING OFFICE POLICY PREVAILS:

  1. All first visit charges are payable when services are rendered
  2. The fee paid for x-rays is for analysis only. We are required to maintain your original x-rays. Films may be loaned to another health provider with your prior authorization only.

If one of your chief concerns is Neck Pain, please fill out our Neck Index below

This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by selecting the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.

Index Score = [Sum of all staements selected / (# of sections with a statement selected x 5)] x 100

If one of your chief concerns is Back Pain, please fill out our Back Index below.

This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by selecting the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.

Index Score = [Sum of all staements selected / (# of sections with a statement selected x 5)] x 100

Your message will be encrypted and can only be read by Elite Pain Relief and Wellness.