Chiropractor Intake Form (Page 4 of 5) in pdf

Chiropractor Intake Form Page 4

By Using the key below, indicate on the body diagram where you are experiencing the following

symptoms:

N=Numbness

B=Burning

S=Sharp

T=Tingling

A=Dull Ache

Average Pain Intensity:

Last 24 hours:

no pain 0 1 2 3 4 5 6 7 8

10 worst pain

Past week:

no pain 0 1 2 3 4 5 6 7 8

10 worst pain

Does anything improve your pain?

Yes No If Yes, please list:

When did your symptoms begin?

________________________________________________

Are your symptoms a result of: ⁫ Motor Vehicle Accident ⁫Work related Accident ⁫ Other_____

How did your symptoms begin? _________________________________________________________

_____________________________________________________________________________________

How often do you experience your symptoms?

⁫ Constantly

⁫ Frequently

⁫ Occasionally

⁫ Intermittently

(76-100% of the day)

(51-75% of the day)

(26-50% of the day)

(0-25% of the day)

What describes the nature of your symptoms?

⁫ Sharp

⁫ Ache

⁫ Numb

⁫ Shooting

⁫ Burning

⁫ Tingling

⁫ Throbbing

⁫ Other ______

Doctor’s Signature ________________________________________

Patient Name_______________________________________________Date______________________

Chiropractor Intake Form Page 4