Patient Forms

Port Jefferson Chiropractic Office, PC

416 Route 25A -Setauket-NY-11733

631-751-7700

Date:

Is this injury due to an automobile accident?

Yes No

Is this injury employment related?

Yes No

Patient Information

Full Name:

First(Legal) MI(Legal) Last

Address:

City:

State:

Zip:

Age:

Birth Date:

I am Under Age18

Yes No

Social Security Number

Email address

Home Phone:

Work Phone:

Cell Phone:

Cell Phone Carrier:

I prefer to receive calls at:

Home Work Cell

Employer:

Business Address:

City:

State:

Zip:

Spouse’s Name:

Spouse’s Date of Birth:

Emergency Contact:

Emergency Contact Phone Number:

Who referred you to our office?

Primary Care Doctor- Name & Phone #

Type "None" if you do not have one.

Payment Information

Person Responsible for Payment:

Social Security Number:

Phone

Date of Birth:

Insurance Information

Do you have health insurance?

Yes No

Primary Insurance

Insurance Company:

Type "None" if you do not have insurance

Policy Holder’s Name:

Type "None" if you do not have insurance

Relationship to Patient:

Type "N/A" if you do not have insurance

Policy Holder’s Birth Date:

Group Number:

Type " None" if one is not available

Policy ID Number:

Type "N/A" if you do not have insurance

Secondary Insurance

Insurance Company:

Policy Holder’s Name:

Relationship to Patient:

Policy Holder’s Birth Date:

Group Number:

Policy ID Number:

Please bring your insurance card and ID so they can be copied for the clinic’s records

1. Describe your symptoms

A. When did your symptoms start?

A specific date or timeframe(week,month,year)

B. How did your symptoms begin?

If not sure type " unknown "

2. How often do you experience your symptoms? Indicate where you have pain or other symptoms

Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day)

3. What describes the nature of your symptoms?

Sharp

Dull ache

Numb

Shooting

Burning

Tingling

4. How are you symptoms changing?

Getting Better Not Changing Getting Worse

5. During the past 4 weeks

B. How much has pain interfered with your normal work (including both work outside the home, and housework)

1-Not at all 2-A little bit 3-Moderately 4-Quite a bit 5-Extremely

6. During the past 4 weeks, how much of the time has your condition interfered with your social activities? (like visiting with friends, relatives, etc)

All of the time Most of the time Some of the time A little of the time None of the time

7. In general, would you say your overall health health right now is...

Excellent Very Good Good Fair Poor

8. Who have you seen for your symptoms?

No one Other Chiropractor Medical Doctor Physical Therapist Other

A. What treatment did you receive and when?

Type "N/A" if you have not seen anyone

B. What tests have you had for your symptoms and when were they performed?

None XRAYS MRI CT Scan Other

When were they performed?

9. Have you had similar symptoms in the past?

Yes No

A. If you are have received treatment in the past for the same or similar symptoms, who did you see?

This Office Other Chiropractor Medical Doctor Physical Therapist Other Did not seek treatment

10. What is your occupation?

Professional/Executive White Collar/Secretarial Tradesperson Laborer Homemaker FT Student Retired Other

A. If you are not retired, a homemaker, or a student, what is your current work status?

Full-time Part-time Self-employed Unemployed Other

What type of regular exercise do you perform?

None Light Moderate Strenuous

What is your height and weight?

Height

Weight

For each of the conditions listed below, select the Past column if you have the condition in the past. If you presently have a condition listed below, select the Present column.

Headaches

Past Present N/A

High Blood Pressure

Past Present N/A

Neck Pain

Past Present N/A

Heart Attack

Past Present N/A

Upper Back Pain

Past Present N/A

Chest Pain

Past Present N/A

Mid Back Pain

Past Present N/A

Stroke

Past Present N/A

Low Back Pain

Past Present N/A

Angina

Past Present N/A

Shoulder Pain

Past Present N/A

Kidney Stones

Past Present N/A

Elbow/Upper Arm Pain

Past Present N/A

Kidney Disorders

Past Present N/A

Wrist Pain

Past Present N/A

Bladder Infection

Past Present N/A

Hand Pain

Past Present N/A

Painful Urination

Past Present N/A

Hip/Upper Leg Pain

Past Present N/A

Loss of Bladder Control

Past Present N/A

Knee/Lower Leg Pain

Past Present N/A

Prostate Problems

Past Present N/A

Ankle/Foot Pain

Past Present N/A

Abnormal Weight Gain/Loss

Past Present N/A

Jaw Pain

Past Present N/A

Loss of Appetite

Past Present N/A

Joint swelling/Stiffness

Past Present N/A

Abdominal Pain

Past Present N/A

Arthritis

Past Present N/A

Ulcer

Past Present N/A

Rheumatoid Arthritis

Past Present N/A

Hepatitis

Past Present N/A

Rheumatoid

Past Present N/A

Liver/Gall Bladder Disorder

Past Present N/A

General Fatigue

Past Present N/A

Cancer

Past Present N/A

Muscular Incoordination

Past Present N/A

Tumor

Past Present N/A

Visual Disturbances

Past Present N/A

Asthma

Past Present N/A

Dizziness

Past Present N/A

Chronic Sinusitis

Past Present N/A

Diabetes

Past Present N/A

Excessive Thirst

Past Present N/A

Frequent Urination

Past Present N/A

Smoking/Use Tobacco Products

Past Present N/A

Drug/Alcohol Dependence

Past Present N/A

Allergies

Past Present N/A

Systemic Lupus

Past Present N/A

Epilepsy

Past Present N/A

Dermatitis/Eczema/Rash

Past Present N/A

HIV/AIDS

Past Present N/A

Females Only

Birth Control Pills

Past Present N/A

Hormonal Replacement

Past Present N/A

Pregnancy

Past Present N/A

Other Health Problems/Issues

Indicate if an immediate family member has had any of the following

Rheumatoid Arthritis Heart Problems Diabetes Cancer Lupus

List all prescription and over-the-counter medications, and nutritional/herbal supplements you are taking:

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List all surgical procedures you have had and times you have been hospitalized:

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NECK INDEX

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

Pain Intensity

0- I have no pain at the moment. 1- The pain is very mild at the moment. 2- The pain comes and goes and is moderate. 3- The pain is fairly severe at the moment. 4- The pain is very severe at the moment. 5- The pain is the worst imaginable at the moment.

Sleeping

0- I have no trouble sleeping. 1- My sleep is slightly disturbed (less than 1 hour sleepless). 2- My sleep is mildly disturbed (1-2 hours sleepless). 3- My sleep is moderately disturbed (2-3 hours sleepless). 4- My sleep is greatly disturbed (3-5 hours sleepless) 5- My sleep is completely disturbed (5-7 hours sleepless).

Reading

0- I can read as much as I want with no neck pain. 1- I can read as much as I want with slight neck pain. 2- I can read as much as I want with moderate neck pain. 3- I cannot read as much as I want because of moderate neck pain. 4- I can hardly read at all because of severe neck pain. 5- I cannot read at all because of neck pain.

Concentration

0- I can concentrate fully when i want with no difficulty. 1- I can concentrate fully when I want with slight difficulty. 2- I have a fair degree of difficulty concentrating when I want. 3- I have a lot of difficulty concentrating when I want. 4- I have a great deal of difficulty concentrating when I want. 5- I cannot concentrate at all.

Work

0- I can do as much work as I want. 1- I can only do my usual work but no more. 2- I can only do most of my usual work but no more. 3- I cannot do my usual work. 4- I can hardly do any work at all. 5- I cannot do any work at all.

Personal Care

0- I can look after myself normally without causing extra pain. 1- I can look after myself normally out it causes extra pain. 2- It is painful to look after myself and I am slow and careful. 3- I need some help but I manage most of my personal care. 4- I need help every day in most aspects of self care. 5- I do not get dressed, I wash with difficulty and stay in bed.

Lifting

0- I can lift heavy weights without extra pain. 1- I can lift heavy weights but it causes extra pain. 2- Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table). 3- Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned. 4- I can only lift very light weights. 5- I cannot lift or carry anything at all.

Driving

0- I can drive my car without any neck pain. 1- I can drive my car as long as I want with slight neck pain. 2- I can drive my car as long as I want with moderate neck pain. 3- I cannot drive my car as long as I want because of moderate neck pain. 4- I can hardly drive at all because of severe neck pain. 5- I cannot drive my car at all because of neck pain.

Recreation

0- I am able to engage in all my recreation activities without neck pain. 1- I am able to engage in all my usual recreation activities with some neck pain. 2- I am able to engage in most but not all my usual recreation activities because of neck pain. 3- I am only able to engage in a few of my usual recreation activities because of neck pain. 4- I can hardly do any recreation activities because of neck pain. 5- I cannot do any recreation activities at all.

Headaches

0- I have no headaches at all. 1- I have slight headaches which come infrequently. 2- I have moderate headaches which come infrequently. 3- I have moderate headaches which come frequently. 4- I have severe headaches which come frequently. 5- I have headaches almost all the time.

BACK INDEX

This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking 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.

Pain Intensity

0- The pain comes and goes and is very mild. 1-The pain is mild and does not vary much. 2- The pain comes and goes and is moderate. 3- The pain is moderate and does not vary much. 4- The pain comes and goes and is- very severe. 5- The pain is very severe and does not vary much I have no back pain

Sleeping

0- I get no pain in bed. 1- I get pain in bed but it does not prevent me from sleeping well. 2- Because of pain my normal sleep is reduced by less than 25%. 3- Because of pain my normal sleep is reduced by less than 50%. 4- Because of pain my normal sleep is reduced by less than 75%. 5- Pain prevents me from sleeping at all

Sitting

0- I can sit in any chair as long as I like. 1- I can only sit in my favorite chair as long as I like. 2- Pain prevents me from sitting more than 1 hour. 3- Pain prevents me from sitting more than 1/2 hour. 4- Pain prevents me from sitting more than 10 minutes. 5- I avoid sitting because it increases pain immediately.

Standing

0- I can stand as long as I want without pain. 1- I have some pain while standing but it does not increase with time. 2- I cannot stand for longer than 1 hour without increasing pain. 3- I cannot stand for longer than 1/2 hour without increasing pain. 4- I cannot stand for longer than 10 minutes without increasing pain 5- I avoid standing because it increases pain immediately.

Walking

0- I have no pain while walking. 1- I have some pain while walking but it doesn't increase with distance. 2- I cannot walk more than 1 mile without increasing pain. 3- I cannot walk more than 1/2 mile without increasing pain. 4-I cannot walk more than 1/4 mile without increasing pain. 5- I cannot walk at all without increasing pain.

Personal Care

0- I do not have to change my way of washing or dressing in order to avoid pain. 1- I do not normally change my way of washing or dressing even though it causes some pain. 2- Washing and dressing increases the pain but I manage not to change my way of doing it. 3- Washing and dressing increases the pain and I find it necessary to change my way of doing it. 4- Because of the pain I am unable to do some washing and dressing without help. 5- Because of the pain I am unable to do any washing and dressing without help.

Lifting

0- I can lift heavy weights without extra pain. 1- I can lift heavy weights but it causes extra pain. 2- Pain prevents me from lifting heavy weights off the floor. 3- Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table). 4- Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned. 5- I can only lift very light weights.

Traveling

0- I get no pain while traveling. 1- I get some pain while traveling but none of my usual forms of travel make it worse. 2- I get extra pain while traveling but it dees not cause me to seek alternate forms of travel 3- I get extra pain while traveling which causes me to seek alternate forms of travel. 4- Pain restricts all forms of travel except that done while lying down. 5- Pain restricts all forms of travel.

Social Life

0- My social life is normal and gives me no extra pain. 1- My social life is normal but increases the degree of pain. 2- Pain has no significant affect on my social life apart from limiting my more energetic interests (e.g., dancing, etc) 3- I get extra pain while traveling which causes me to seek alternate forms of travel. 4- Pain has restricted my social life to my home. 5- l have hardly any social life because of the pain.

Changing degree of pain

0- My pain is rapidly getting better. 1- My pain fluctuates but overall is definitely getting better. 2- My pain seems to be getting better but improvement is slow 3- My pain is neither getting better or worse. 4- My pain is gradually worsening. 5- My pain is rapidly worsening. I have no back pain

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name

Signature of Patient/Guardian

Date

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