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Patient Information
Full name
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Date of Birth
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Month
Day
Year
Age
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Phone
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Email
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Address
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Employer
Occupation
Emergency Contact
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Emergency Phone
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Chief Complaint
What brings you in today?
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When did this begin?
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Pain Level (0-10)
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How did this start?
*
Gradually
Injury
Auto Accident
Sports
Work
Unknown
Pattern of Symptoms:
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Constant
Comes and Goes
Getting Worse
Improving
Symptoms – check all that apply:
*
Sharp
Dull
Aching
Burning
Stiffness
Tingling
Numbness
Weakness
What makes it worse?
*
Sitting
Standing
Walking
Bending
Lifting
Sleeping
Exercise
What helps?
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Rest
Movement
Ice
Heat
Stretching
Medication
Nothing
Functional Limitations:
*
Work
Exercise
Sleep
Sitting
Walking
Driving
Daily tasks
Previous treatment for this issue:
*
None
Chiropractor
Medical doctor
Imaging
Injections
Surgery
Neck Pain Section
Check all that apply:
Pain with rotation
Pain looking up/down
Pain into shoulder/arm
Numbness/tingling in arm/hand
Weakness in arm/hand
Headaches with neck pain
How often is your neck pain present?
Wat movements or activities aggravate it?
Describe your neck pain:
Low Back Pain Section
Check all that apply:
Pain with sitting
Pain with standing
Pain bending forward
Pain into buttock/leg
Numbness/tingling in leg/foot
Weakness in leg
Pain with coughing/sneezing
Morning stiffness
Pain changing positions
How often is your low back pain present?
What movements or activities aggravate it?
Describe your low back pain:
Headache Section
Check all that apply:
Tension type
Migraine
Behind eyes
Base of skull
Light sensitivity
Nausea
Sound sensitivity
Headache with neck pain
How often do your headaches occur?
How long do they usually last?
Describe your headaches:
Health History
Check all that apply:
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High blood pressure
Heart disease
Diabetes
Cancer
Stroke
Arthritis
Osteoporosis
Neurological disorder
None
Other medical history:
Surgical history:
Current medications:
Allergies:
Important Screening
Check all that apply:
Unexplained weight loss
Fever/chill
Loss of bowel/bladder control
Severe night pain
Dizziness.fainting
Recent trauma
Lifestyle & Goals
Exercise frequency:
Hours of sleep/night:
Water intake:
What are your goals for care?
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Patient Signature:
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Date:
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