Patient Paperwork

Date

Name (First, MI, Last):

Preferred name:

Address:

City:

State:

Zip:

Date of birth:

Social security number:

Email address

Cell phone number:

Home phone number:

Gender

Male Female Prefer not to respond

Preferred method of contact

Phone Text Email

Referred by:

Emergency Contact Information:

Name:

(First, MI, Last)

Contact number

Relationship

Primary care physician:

Doctor's Phone:

Financial Information:

Is today's visit the result of an accident?

Auto

Work

Other

Will we be working with insurance?

Yes

If yes, be sure to bring your insurance card with you.

Primary:

Secondary:

Insurance member ID

Where would you like your statements sent?

Self

Other

(Details below)

Name:

Address:

Phone number:

Email:

History of Present Illness (Please describe):

Major complaint:

Secondary complaints:

When did it start?

What happened?

What daily activities are being affected by this condition?

Major Complaint Details:

Quality:

Sharp

Stabbing

Burning

Achy

Dull

Stiff & sore

Does it radiate?

Yes

If yes, where:

Frequency:

Off & On

Constant

If other, please explain:

Worsens with:

Sitting

Standing/Walking

Lying Down/Sleeping

Overuse/Lifting

Other

Please explain

If other, please explain:

Previous treatment:

None

Chiropractor

Medical doctor

Physical therapy

ER/Urgent care

Orthopedic

Other

Please explain

If other, please explain:

Women: Are you pregnant?

Yes

Last menstrual period:

Due date:

Prescription medications & supplements:

None

Yes

If yes, please list medications & supplements below:

(Name, dosage, & frequency)

Allergies to medications, food, other:

No known allergies

Yes

Please list

If yes, please list allergies below:

(Name and reaction)

Review of Systems:

Many of the following conditions respond to chiropractic treatment.

Are you CURRENTLY experiencing any of these symptoms? (Please select all that apply and us comments to elaborate)

Constitutional (General):

Fever

Fatigue

Other

Please explain in comments

None in this category

Respiratory:

Difficulty breathing

Cough

Other

Please explain in comments

None in this category

Cardiovascular & Heart:

Chest pain/tightness

Rapid or heartbeat changes

Swelling of hands, ankles, or feet

Other

Please explain in comments

None in this category

Allergic/Immunologic:

Food allergies

Environmental allergies

Other

Please explain in comments

None in this category

Review of systems comments:

Functional Rating Index:

In order you properly assess your condition, we must understand how much your condition has affected your ability to manage everyday activities.

For each item below, please select the number which most closely describes our condition right now.

Personal, Family, and Social History

Have you EVER had any of the following? (Please select all that apply and use comments to elaborate)

Injuries:

Back injury

Broken bones

Head injury

Neck injury

Falls

Other

Please list in comments

None

Please elaborate:

Hospitalizations:

Non-surgical

Other hospitalizations:

Non-surgical

Surgeries:

Cancer

Orthopedic

Shoulder, elbow/forearm, wrist/hand, hip, knee, ankle/foot

Spinal

Neck or back

Other

Please list in comments

None

Please elaborate:

Family History:

Please select all that apply and use comments to elaborate.

Unknown

Unremarkable

Age at death (if deceased)

Gender and age at death (if deceased)

Please list any other family medical history below:

Social and Occupational History:

If yes, what is your occupation?

Dominant hand:

Right

Left

Ambidextrous

Comments:

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