Chiropatic Intake Form (Page 4 of 5) in pdf

REVIEW OF SYSTEMS

Please check all that apply to current or previous health history (especially in the last 6 months).

GENERAL

NECK

GENITO-URINARY

___

____Pain

____

Nervousness

Difficulty urinating

____Stiffness

____Irritability

____Pain with urination

____Grinding/popping

____Depression

____Blood in urine

____Muscle Spasm

____Fatigue

____Change (amt & frequency)

____Swelling

____Sleep disturbances

____Prostate changes/problems

____Weight changes

____Intercourse problems

____Fever

HEAD

CHEST

UPPER EXTREMITY

____

____Pain

(

)

Headache

____Pain

(circle)

circle

____Shortness of breath

Entire head/Back of Head/

Upper Arm/Forearms/

____Pain around ribs

Temple/Forehead/Migraines

Hands/Fingers

____Cough

____Head trauma

____

Pins & Needles (circle)

____Dizziness

Arms/Fingers

MIDBACK

____Fainting

____Numbness

____

____Lighted headedness

Tired/weakness

____Cold hands/fingers

____Memory loss

____Muscle spasm

____Swollen or sore joints

____Sharp pain with breathing

____Loss of strength

EYES

LOW BACK

WOMEN ONLY

____Change in vision

____

Pain

Irregular periods

____Glasses/contacts

____Muscle spasm

____Menstrual cramps

____Blurry vision

____Condition worsens with

____PMS

(circle)

____Double vision

Work/Lifting/Standing/Sitting/

____Menstrual Migraines

____Flashes/spots

Coughing/Sneezing/Lying down/

____Hot flashes

____Light sensitive

Rest/Activity

____Menopause

____Lumps in breast

____Nipple discharge

EARS

GASTROINTESTINAL

LOWER EXTREMITY

____Ringing

____

Heartburn

Pain

(circle)

____Hearing loss

____Indigestion

Buttocks/hip joint

____Frequent infection

____Gas

____

Pain travels

(circle)

____Pain

____Abdominal Pain

Down one leg/Down both

____Buzzing

____Bloating

____

Cramping

____Drainage

____Nausea/Vomiting

____

Pins & Needles

(circle)

____Diarrhea

Gluts/Feet/Toes

NOSE

____Constipation

____

Numbness

____Nosebleeds

____Blood in Stool

(circle)

Legs/Feet/Toes

____Sinus problems

____Difficulty in Bowel Control

____

Swollen Ankles

MOUTH/THROAT

____

Painful toe joint

____Jaw pain

____

Painful knee joint

____Change in taste

____Hoarseness

____Trouble swallowing

____Slurred speech

Chiropatic Intake Form Page 4

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