Chiropractic Intake Form - Essential Health Chiropractic printable pdf download

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

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.

Chiropractic Intake Form - Essential Health Chiropractic