Chiropractic Enrollment Form Page 2
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1
2Describe Your Current Problem And How It Began:
Describe Your Current Problem And How It Began:
Describe Your Current Problem And How It Began:
Mark an “X” on the picture where you have pain or other symptoms.
Mark an “X” on the picture where you have pain or other symptoms.
Mark an “X” on the picture where you have pain or other symptoms.
□ Headache □ Neck pain □ Mid-back pain
□ Headache □ Neck pain □ Mid-back pain
□ Headache □ Neck pain □ Mid-back pain
□ Lower back pain
□ Lower back pain
□ Lower back pain
□ Other _______________________________________________
□ Other _______________________________________________
□ Other _______________________________________________
Is this problem
Is this problem
Is this problem
work related / Auto related / None
work related / Auto related / None
work related / Auto related / None
Date Problem Began: _____________________________________
Date Problem Began: _____________________________________
Date Problem Began: _____________________________________
How Problem Began: _____________________________________
How Problem Began: _____________________________________
How Problem Began: _____________________________________
Have you been treated for this problem? _____________________
Have you been treated for this problem? _____________________
Have you been treated for this problem? _____________________
Current Pain level (0=no pain, 10 = worst pain imaginable)
Current Pain level (0=no pain, 10 = worst pain imaginable)
Current Pain level (0=no pain, 10 = worst pain imaginable)
0
0
0
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
7
7
7
8
8
8
9
9
9
10
10
10
How often are you r symptoms present? (Circle one)
How often are you r symptoms present? (Circle one)
How often are you r symptoms present? (Circle one)
0-25%
0-25%
0-25%
26-50%
26-50%
26-50%
51-75%
51-75%
51-75%
76-100%
76-100%
76-100%
In the past week, how much has you pain interfered with your daily activities (i.e. social acitivites,
In the past week, how much has you pain interfered with your daily activities (i.e. social acitivites,
In the past week, how much has you pain interfered with your daily activities (i.e. social acitivites,
house hold chores, work, etc.)?
house hold chores, work, etc.)?
house hold chores, work, etc.)?
Current Pain level (0=no interference, 10 = unable to do carry on any activities)
Current Pain level (0=no interference, 10 = unable to do carry on any activities)
Current Pain level (0=no interference, 10 = unable to do carry on any activities)
0
0
0
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
7
7
7
8
8
8
9
9
9
10
10
10
Have you had spinal x-rays, MRI, CT-Scan for your areas of complaint? ___ Yes
Have you had spinal x-rays, MRI, CT-Scan for your areas of complaint? ___ Yes
Have you had spinal x-rays, MRI, CT-Scan for your areas of complaint? ___ Yes
___ No
___ No
___ No
Date(s) taken: _____________________________________ What areas were taken? _______________
Date(s) taken: _____________________________________ What areas were taken? _______________
Date(s) taken: _____________________________________ What areas were taken? _______________
Please check all of the following that apply to you:
Please check all of the following that apply to you:
Please check all of the following that apply to you:
□ Recent fever
□ Recent fever
□ Recent fever
□ Diabetes
□ Diabetes
□ Diabetes
□ High blood pressure
□ High blood pressure
□ High blood pressure
□ Stroke (date) _________
□ Stroke (date) _________
□ Stroke (date) _________
□ Corticosteroid use (cortisone, prednisone, etc.)
□ Corticosteroid use (cortisone, prednisone, etc.)
□ Corticosteroid use (cortisone, prednisone, etc.)
□ Taking birth control pills
□ Taking birth control pills
□ Taking birth control pills
□ Numbness in groin/buttocks
□ Numbness in groin/buttocks
□ Numbness in groin/buttocks
□ cancer / tumor (explain) _________________
□ cancer / tumor (explain) _________________
□ cancer / tumor (explain) _________________
□ Osteoporosis
□ Osteoporosis
□ Osteoporosis
□ Epilepsy / Seizures
□ Epilepsy / Seizures
□ Epilepsy / Seizures
□ Prostate problems
□ Prostate problems
□ Prostate problems
□ Menstrual problems
□ Menstrual problems
□ Menstrual problems
□ Urinary problems
□ Urinary problems
□ Urinary problems
□ Currently pregnant # weeks _____
□ Currently pregnant # weeks _____
□ Currently pregnant # weeks _____
□ Abnormal weight gain / loss
□ Abnormal weight gain / loss
□ Abnormal weight gain / loss
□ Marked morning pain/stiffness
□ Marked morning pain/stiffness
□ Marked morning pain/stiffness
□ Pain unrelieved by position or rest
□ Pain unrelieved by position or rest
□ Pain unrelieved by position or rest
□ Pain at night
□ Pain at night
□ Pain at night
□ Surgeries _____________________________
□ Surgeries _____________________________
□ Surgeries _____________________________
□ visual disturbances
□ visual disturbances
□ visual disturbances
□ Medications: __________________________
□ Medications: __________________________
□ Medications: __________________________
□ Dizziness/fainting
□ Dizziness/fainting
□ Dizziness/fainting
Family History
Family History
Family History
□ Cancer
□ Cancer
□ Cancer
□ Diabetes
□ Diabetes
□ Diabetes
□ High Blood Pressure
□ High Blood Pressure
□ High Blood Pressure
□ Heart Problems/ Stroke
□ Heart Problems/ Stroke
□ Heart Problems/ Stroke
□ Rheumatoid arthritis
□ Rheumatoid arthritis
□ Rheumatoid arthritis
PLEASE READ AND SIGN BELOW:
PLEASE READ AND SIGN BELOW:
PLEASE READ AND SIGN BELOW:
I certify to the best of my knowledge, the above information is complete and accurate. I understand the clinic
I certify to the best of my knowledge, the above information is complete and accurate. I understand the clinic
I certify to the best of my knowledge, the above information is complete and accurate. I understand the clinic
will verify my insurance coverage, however if the health plan information received from the insurance
will verify my insurance coverage, however if the health plan information received from the insurance
will verify my insurance coverage, however if the health plan information received from the insurance
carrier is not accurate, or if I am not eligible to receive health care benefits through this provider, I
carrier is not accurate, or if I am not eligible to receive health care benefits through this provider, I
carrier is not accurate, or if I am not eligible to receive health care benefits through this provider, I
understand that I am liable for all charges for services rendered. I agree to notify this doctor immediately
understand that I am liable for all charges for services rendered. I agree to notify this doctor immediately
understand that I am liable for all charges for services rendered. I agree to notify this doctor immediately
whenever I have changes in my health condition or health plan coverage in the future. I understand that my
whenever I have changes in my health condition or health plan coverage in the future. I understand that my
whenever I have changes in my health condition or health plan coverage in the future. I understand that my
doctor of chiropractic may need to contact my medical doctor if my condition needs to be co-managed.
doctor of chiropractic may need to contact my medical doctor if my condition needs to be co-managed.
doctor of chiropractic may need to contact my medical doctor if my condition needs to be co-managed.
Therefore, I give authorization to my chiropractor to contact my physician, if necessary.
Therefore, I give authorization to my chiropractor to contact my physician, if necessary.
Therefore, I give authorization to my chiropractor to contact my physician, if necessary.
Patient Signature: ____________________________________ Date: _____________
Patient Signature: ____________________________________ Date: _____________
Patient Signature: ____________________________________ Date: _____________
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