Chiropractic Intake Form
Dr. Elise DeCamp, DC, CCWP, CACCP
Patient Information:
Name: _____________________________________________
Date: __________________________________
Address: ___________________________________________________________________________________________
Sex: Male
Female
Date of Birth: _______________
Height:_________________ Weight: ______________
Patient SSN: ____________________________ [Married / Single / Other] Spouse:_______________________________
Home Phone:_____________________ Cell Phone: ______________________ Work Phone: _____________________
Email:_________________________________________________ Would you like our newsletter emailed to you: Y N
Whom may we thank for referring you? _________________________________________________________________
Emergency Contact:_________________________________________ Phone: _________________________________
Employer: _________________________________________________________ Is it okay to contact you at work? Y N
Employer Address: ___________________________________ Employer Phone: ________________________________
Present Complaint: __________________________________________________________________________________
When did this begin?______________________________________ Was there an accident or injury involved? Y N
Was this due to a car accident? Y N
Was this due to an accident from work? Y N
Have you had any past treatment for this complaint? Y N Describe:__________________________________________
Medications/supplements (Last 6 months to present): ____________________________________
How did this complaint start: __________________________________________________________________________
What is the nature of the symptoms: Dull Ache Burn Throb Deep Sharp Shooting _________________________
How often are you experiencing the symptoms: Constant (100 %) Frequent (75%) Often (50%) Intermittent (25%)
Since the symptoms started have they gotten: Better Worse Stayed the Same
On a scale of 0-10, 10 being the worst, how do you rate your discomfort: _________/10
Have the symptoms affected your ability to sleep? Y N Have they affected your appetite? Y N
Do you have any radiation of pain? Y N Is there anything that makes your discomfort Better or Worse? ____________
How do you rate your health today: Excellent Very Good
Good
Poor
Have you been to a chiropractor before? Y N
When was your last visit? ____________________________________
How would you rate your diet? ____ Well Balanced ____ Average ____High sugar/processed foods
Does you consume artificial sweeteners? Y
N
How many times per week do you engage in physical activity: __________
Please mark on the diagram below where you are feeling the symptoms you described.