CHIEF COMPLAINT -What is your complaint or why are you seeking chiropractic care? *
Your answer
ONSET - How long have you had this condition? *
Your answer
TIMING *
When did this begin? *
Your answer
PALLIATIVE- What activities/treatments improve the condition? *
Required
CAUSE -What caused the condition or what circumstance preceded the symptoms? *
Your answer
OTHER TREATMENT- Have you been treated or treated yourself for this condition. *
Required
If you have ever had this condition before, please describe the timing a circumstances. *
Your answer
Symptoms radiating to or affecting the extremities.
Upper extremities include shoulders, arms, elbows, forearms, wrists and fingers. Lower extremities include hip, thighs, knee, leg, ankles, feet and toes.
EXTREMITIES - Do you have any symptoms that seem to radiate to your *
Required
Do you have incontinence (loss of bowel or bladder control)? *
Required
What is the extreme LEVEL of your condition be it pain or discomfort, if 10 is the worst? *
BETTER
WORSE
What is the extreme LEVEL of your condition be it pain or discomfort, if 10 is the worst? *
BETTER
WORSE
What is the FREQUENCY of your symptoms? *
PROVOCATIVE -What activities increase the condition? *
Required
PROVOCATIVE OTHER - Are there any activities not listed above the exacerbate your symptoms?
Your answer
PALLIATIVE -What activities decrease the condition? *
Required
PALLIATIVE OTHER -Is there anything not listed above that decreases your symptoms?
Your answer
QUALITY -How does it feel? *
Required
Do you describe your pain in a different way than listed above?
Your answer
If you have other complaints or concerns you may discuss them here.
Your answer
Rx/SUPPLEMENTS -Please list any medications and supplements/vitamins that you are taking. *
Your answer
How much alcohol do you consume? *
Your answer
What is your SMOKING-(if currently smoking please indicate the number of cigarettes or cigars)? *
Your answer
What is. your OCCUPATION? *
Your answer
What is your EXERCISE regimen? *
Required
If your physical activity was not listed, please describe it here.
Your answer
PAST MEDICAL HISTORY *
Required
PROCEDURES/SURGERIES/OTHER CONDITIONS - Do you have any history of other conditions/surgeries/procedures not listed above? please list dates. You may give a document with this information at the time of your appointment. *
Your answer
FAMILY Medical history- *
Required
Do you have a PACEMAKER or any other electrical device. *
Are you PREGNANT or attempting to become pregnant *
CONSTITUTIONAL-Do you have or have you had? *
Required
MUSCULOSKELETAL- Mark any symptoms you may have. *
Required
NEUROLOGICAL- Mark any symptoms you may have. *
Required
ACTIVITIES OF DAILY LIVING - Which are affected by your condition. *
Required
Are there any other activities affected by your condition?