Patient Intake Form - Advanced Spinal Care Page 2
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3MEDICARE PATIENTS (check one): Would you like to be able to
Bend and lift with no pain
Get up from sitting with no pain
Get a good night’s sleep with no pain
Read with no pain
Work at a computer with no pain
Do your housework with no pain
Do your yard work with no pain
Play sporting activities with no pain
Current Health
• Name and phone number of family doctor: ________________________________________________________________________
• List all CURRENT illnesses or diseases you have been diagnosed with (cancers, tumors, infections, diabetes, aneurysms, etc.):
________________________________________________________________________ Date of late eye exam: _________________
• If you are currently taking any prescription or nonprescription medications, please list them below with dosages:
Medication: _______________________________ Dose: ______ Medication: _______________________________ Dose: ________
Medication: _______________________________ Dose: ______ Medication: _______________________________ Dose: ________
• Please list any medications you are allergic to: ______________________________________________________________________
• Please indicate your height and weight ___________________________________What is your usual blood pressure______/_______
Health History
• List any operations, surgeries or medical procedures:
Date:____________ Procedure: ____________________________ Date:____________ Procedure: ____________________________
Date:____________ Procedure: ____________________________ Date:____________ Procedure: ____________________________
• If you have ever had in the past or currently have any serious illnesses or injuries, please list:
Date:____________ Condition: ____________________________ Date:____________ Condition: ____________________________
Date:____________ Condition: ____________________________ Date:____________ Condition: ____________________________
Any current loss of bowel or bladder control:
Yes
No Any current seizures, paralysis, speech, vision problems:
Yes
No
Any unexplained recent weight loss:
Yes
No Current fever:
Yes
No
Current nutritional problems:
Yes
No
• Please list any significant family illnesses___________________________________________________________________________
• Have you had spinal X-Rays within the past 5 years? If yes, when and where _____________________________________________
• Do you have a pacemaker?
Yes
No If yes, please ALERT our doctor and/or chiropractic assistant
• Do you have any blood/lymph disorders?
Yes
No If yes, please list ________________________________________________
• Do you have osteoporosis or rheumatoid arthritis?
Yes
No
• Please list any other electrical device that you currently wear___________________________________________________________
• Please select one:
I have never smoked
Former smoker
Current smoker, if so how much: ____ pk./day ____ pk./wk.
• Please select one:
I don’t drink alcohol
Rarely drink
Social drinker
Heavy drinker (_____ oz. per day/week)
• Have you ever had chiropractic care
Yes
No If yes, last date of treatment____________ By whom: ____________________
Similar or difference condition:________________________ Results: _____________________________________________________
What are your overall expectations from your treatment with our doctor: ________________________________________________
I, the undersigned, hereby give my consent for the doctor to examine and treat my condition as he/she deems appropriate through
the use of Chiropractic care. I also give my consent to the doctor to take x-rays (if needed) or to perform other diagnostic aids as
he/she deems appropriate in my case.
• WOMEN ONLY I hereby declare that to the best of my knowledge
I am
I am not pregnant. If there is a chance that I may be
pregnant, I will inform the doctor prior to my examination.
Patient Signature_________________________________________________
(Parent/Guardian signature if under 18 years of age)
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