Please Complete and Print these forms, ready for your visit. (Time Saver)
Please describe your symptoms and how they began:
Onset date of your symptoms?
Have you had similar symptoms in the past?
Yes No
Please circle all that apply
How often do you experience your symptoms? Constantly (76-100% of the day), Frequently (51-75%), Occasionally (26-50%), Intermittently (0-25%)
What describes the nature of your symptoms? Sharp, Dull Ache, Numbness, Shooting, Burning, Tingling, Stabbing, Pins and Needles
How are your symptoms changing? Getting better, Not changing, Getting Worse
During the past 4 weeks, indicate the average intensity of your symptoms: 1 being no pain - 10 being unbearable
During the past 4 weeks, how much has pain interfered with work in and out of the home? Not at all, A little bit, Moderately, Quite a bit, Extremely
During the past 4 weeks, how much has your condition interfered with your social activities? All of the time, Most of the Time, Some of the time, A little of the time, None of the time
In general would you say your overall health right now is? Excellent, Very good, Good, Fair, Poor
Who have you seen for your symptoms? No one, Other Chiropractor, Medical Doctor, Physical Therapist, Other
What treatment did you receive for your symptoms? Adjustments, Physical therapy, Medication, Surgery, Other
When did you receive this treatment? In the last month, 2-3 months ago, 6 months to 1 year, 1-2 years, 2-5 years, 5-10 years
What tests did you have for your symptoms? X-rays, MRI, CT Scan, Other
When were these tests done? In the last month, 2-3 months ago, 3-6 months,
6 months - 1 year, 1-2 years, 2-5 years, 5-10 years
If you 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
What is you occupation? Professional/Executive, White Collar/Secretarial, Trades person, Laborer, Homemaker, FT Student, Retired, Other
If you are not retired, a homemaker, or a student, what is your current work status?
Full time, Part time, Self employed, Unemployed, Off work, Other,
Disabled/Date Disabled
