Patient Entrance Form Welcome To Khouri Chiropractic And Health Solutions, Llc
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6PATIENT ENTRANCE
FORM
Welcome to Khouri Chiropractic and Health Solutions, LLC
Widowed
Patient
Information
Welcome I How did you hear about our office?
_
Patient Name: First
MI
last
_
Social Security
#
Date of Birth
_
Street Address
Apt #
_
City
_
Phone: Cell (__
)
Home
(.---J
Work (__
)
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Email:
_
Marital Status: Single __
Married
Divorced
Occupation:
Employer
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Health Insurance Company:
Policy #:
_
Insured's Name
Insured's Date of Birth
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Emergency Contact:
Phone
# (_)
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What do you enjoy doing most in life?
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State
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ZipCode
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What brings you to our office?
First Complaint:
_
Have you ever been to another doctor for this problem?
Y N Who?
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On what date did your symptom first appear?
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Did the symptom appear:
Gradually __
Suddenly
Progressively Over Time
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What do you do that makes the symptom better?
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What do you do that makes the symptom worse?
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Does the pain feel:
Dull
_
Sharp _
Ache _
Numb _
Cramp _
Throb _
Other __
Does your pain radiate into your:
Arm __
leg __
Does not Radiate
How much of the day do you feel the symptom?
100%_
75%_
50%_
25%_
10%_
Do you notice the symptom is worse during any certain time of the day?
_
On a scale of 1-10 with 10 being the worst, what would you rate the pain right now?
Patient
Signature
Date __
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