Chiropatic Intake Form (Page 2 of 5) in pdf

Chiropatic Intake Form Page 2

What is the main problem? When did it begin? How? ___________________________________

_____________________________________________________________________________

Have you had this or a similar problem in the past? If Yes, please explain___________________

_____________________________________________________________________________

Does anything aggravate it? ______________________________________________________

Does anything make it better? ____________________________________________________

Does the complaint radiate/travel to other areas? _____________________________________

Rate the severity of the pain? (no pain) 0

10 (extreme)

How often does it occur? (never) 0

10 (constant)

Activities/movements difficult to perform: sit stand walk bend lay down (circle all that apply)

Have you received treatment for this elsewhere or being co-managed concurrently?

Massage

Medical doctor

Physiotherapy

Chiropractor

Other____________

Are you currently on any medications, herbs, vitamins, supplements, birth control? __________

_____________________________________________________________________________

Do you have any allergies? _______________________________________________________

Name of your medical doctor? _____________________________________________________

PAST HISTORY

Have you ever had any of the following:

Describe

Date

Surgeries:

Injuries:

Auto Accidents:

Hospitalizations:

Major Illnesses:

Chiropatic Intake Form Page 2