Patient Intake Form
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1
2PATIENT INTAKE FORM
Patient Name: _____________________________
Date: _______________
1. Is today's problem caused by: □ Auto Accident
□ Workman's Compensation
2. Indicate on the drawings below where you have pain/symptoms
3. How often do you experience your symptoms?
□ Constantly (76-100% of the time)
□ Occasionally (26-50% of the time)
□ Frequently (51-75% of the time)
□ Intermittently (1-25% of the time)
4. How would you describe the type of pain?
□ Sharp
□ Numb
□ Dull
□ Tingly
□ Diffuse
□ Sharp with motion
□ Achy
□ Shooting with motion
□ Burning
□ Stabbing with motion
□ Shooting
□ Electric like with motion
□ Stiff
□ Other:___________________
5. How are your symptoms changing with time?
□ Getting Worse
□ Staying the Same
□ Getting Better
6. Using a scale from 0-10 (10 being the worst), how would you rate your problem?
0
1
2
3
4
5
6
7
8
9
10 (Please circle)
7. How much has the problem interfered with your work?
□ Not at all
□ A little bit
□ Moderately
□ Quite a bit
□ Extremely
8. How much has the problem interfered with your social activities?
□ Not at all
□ A little bit
□ Moderately
Quite a bit
□ Extremely
9. Who else have you seen for your problem?
□ Chiropractor
□ Neurologist
□ Primary Care Physician
□ ER physician
□ Orthopedist
□ Other:_____________
□ Massage Therapist
□ Physical Therapist
□ No one
10. How long have you had this problem? ___________
11. How do you think your problem began?
___________________________________________________________________________________
12. Do you consider this problem to be severe?
□ Yes
□ Yes, at times
□ No
13. What aggravates your problem?
____________________________________________________________________________________
14. What concerns you the most about your problem; what does it prevent you from doing?
____________________________________________________________________________________
15. What is your: Height___________
Weight _____________
Age ___________
Occupation _____________________________________________________
16. How would you rate your overall Health?
□ Excellent
□ Very Good
□ Good
□ Fair
□ Poor
17. What type of exercise do you do?
□ Stenuous
□ Moderate
□ Light
□ None
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Parent category: Business