PATIENT INTAKE FORM - CHIROPRACTIC
_______ I understand that 24 hours is required to cancel any appointments, otherwise I will be charged a $30 late
cancellation/no-show fee.
Patient Name:_____________________________________________________ Birth Date (D/M/Y):____/___/_______
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Age: _____ Gender:
Female
Male
Email:_________________________________________________________
Address:_____________________________________ City:__________________________ Postal code:______________
Phone (Home):_________________________________ Phone (Cell):__________________________________________
Occupation:_______________________________
Family Doctor:___________________________________________
How did you hear about our clinic? _______________________________ Referred By: ___________________________
Please mark where the pain is located.
ADDRESSING THE ISSUE THAT BROUHT YOU TO OUR OFFICE
1. What is your major symptom/problem?___________________________
2. When did your symptoms begin?________________________________
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3. Have you had this problem before?
Yes
No
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4. Is the problem there –
constant
comes & goes
with use
at rest?
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5. Is the problem getting -
worse
no change
better?
6. What makes it worse?______________________________________
7. What makes it better?______________________________________
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8. How does it feel?
Burning
Sharp
Shooting
Dull
Stiff
Aching
Tingling
Throbbing
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Swelling
Other:_______________________
9. How would you rate the sensitivity of your pain ( 0=no pain, 10=severe pain)? ______
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10. Does it interfere with your:
Work
Sleep
Daily Routine
Recreation?
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11. What test have you had for this condition?:
Spinal Exam
X – ray
MRI
CT Scan
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12. Have you received any treatment for this condition?
Orthopedic
Physiotherapy
Massage Therapy
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Acupuncture
Surgery (Date D/M/Y: _______________) Other: __________________________