Neuropathy Patient

Please fill out the application entirely and legibly.

Name (First Name, Middle Initial, Last Name)

Nickname

Address

City

State

Zip Code

Phone

*We will need to contact you both by phone & email. Please be sure to give us the best phone number to reach you*

Date of Birth

Social Security

Spouse Name

Phone Number

Your Occupation

Retired

Yes No

Review of Symptoms

Present Health Condition

01 In order of importance, list the health problems you are most interested in getting corrected:

02 Is there a certain time of day any of these problems are better or worse?

03 Is your balance/walking ability affected? If yes, please describe.

04 List approximately how long you have noticed these problems in your life:

06 What do you think is causing your problem?

07 Name of all doctors you have seen for these problems and treatment you received

08 Have your symptoms

Improved Worsened Stayed the Same

List anything that makes your condition worse

List anything that makes your condition better

10. Is this condition interfering with any of the following?

Sleep

Recreational Activities

Work

Walking

Daily Activities

Standing

Social History

Do you smoke?

Yes No

If yes, how many cigarettes daily?

Do you drink?

Yes No

If yes, how many drinks per week?

Do you exercise?

Yes No

If yes, please describe type and how often?

Current Pain Levels

Previous Health Conditions

This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization.

Name

Please give name, address, and office phone number of your primary care physician.

Name

Phone

Address

When were you last seen there?

May we send them updates on your treatment/condition?

Yes No

List ALL allergies/sensitivities to medication, food, and other items here:

Add new row

List the prescription drugs you are currently taking (or you may attach a list):

Attach a list

Add file

Please upload a file

Add new row

List all nutritional supplements (vitamins, herbs, homeopathics, etc.) as above:

Add new row

Patient Quality of Life Survey

Patient Name

Date

Please take several minutes to answer these questions so we can help you get better.
(Please check all that apply)

01 How have you taken care of your health in the past?

Medications

Emergency Room

Routine Medical

Exercise

Other

Nutrition/Diet

Holistic Care

Vitamins

Chiropractic

If other, please specify

02 How did the previous method(s) work out for you?

Bad Results

Some Results

Great Results

Nothing Changed

Did Not Get Worse

Did Not Work Very Long

Still Trying

Confused

03 How have others been affected by your health condition?

No One Is Affected

Haven’t Noticed Any Problem

They Tell Me To Do Something

People Avoid Me

04 What are you afraid this might be (or beginning) to affect (or will affect)?

Job

Kids

Future Ability

Marriage

Self-Esteem

Sleep

Time

Finances

Freedom

05 Are there health conditions you are afraid this might turn into?

Family Health Problems

Heart Disease

Cancer

Diabetes

Arthritis

Fibromyalgia

Depression

Chronic Fatigue

Need Surgery

06 How has your health condition affected your job, relationships, finances, family, or other activities? Please give examples:

07 What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.). Give 3 examples:

08 What are you most concerned with regarding your problem?

09 Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specific.

10 What would be different/better without this problem? Please be specific.

11 What do you desire most to get from working with us?

12 What would that mean to you?

Your information will be encrypted.

Neuropathy Patient

Please fill out the application entirely and legibly.

Review of Symptoms

Present Health Condition

Social History

Current Pain Levels

Previous Health Conditions

Patient Quality of Life Survey

Dr. Matthew C. Zimmerman