Patient Intake Form - Chiropractic
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1Thacker Chiropractic Clinic
Patient Name: ____________________________________ Birthdate: _ _______________
Sex: M / F
Address: ________________________________________ City: ___________________ State: __________
Zip: _________ Telephone: (____)_____________Cell: (_____)______________ SSN # ________________
Occupation: _______________________ Employer: _______________________ Work: (_____)__________
E-mail: _______________________________
Mark an X on the picture
Describe your current problem and how it began:
Headache
Neck Pain
Mid-back pain
Low back pain
where you have pain
Is this:
Work Related
Auto Related
N/A
Date Problem Began: _________________________________
How Problem Began: _________________________________
Current complaint (how you feel today)
___________________________________________
0
1
2
3
4
5
6
7
8
9
10
No pain
Unbearable pain
How often are your symptoms present?
(Intermittent)
0 - 25%
26 - 50%
51 - 75%
76 - 100% (Constant)
In the past week, how much has your pain interfered with your daily activities
?
(e.g. work, social activities, or household chores)
____________________________________________
0
1
2
3
4
5
6
7
8
9
10
No interference
Unable to carry on any activities
Have you had spinal X-rays, MRI, CT scan for your area(s) of complaint?
No
Yes
Please check all of the following that apply to you:
Recent Fever
Prostate Problems
Diabetes
Menstrual Problems
High Blood Pressure
Urinary Problems
Stroke (date) ____________________
Currently Pregnant, # weeks ______ ____________
Corticosteroid Use (cortisone, prednisone, etc.)
Abnormal Weight
Gain
Loss
Taking Birth Control Pills
Marked Morning Pain/Stiffness
Dizziness/ Fainting
Pain Unrelieved by Position or Rest
Numbness in Groin/ Buttocks
Pain at night
Cancer/ Tumor (explain) _____________
Visual Disturbances
________________________________
Surgeries: ____________________________________
Osteoporosis
____________________________________________
Epilepsy/ Seizures
____________________________________________
Other Health Problems (explain) ______
Medications: __________________________________
________________________________
____________________________________________
________________________________
____________________________________________
Family History:
Cancer
Diabetes
High Blood Pressure
Heart Problems/ Stroke
Rheumatoid Arthritis
I certify to the best of my knowledge the above information is complete and accurate. If the health plan information is not
accurate, or if I am not eligible to receive a health care benefit through this provider, I understand that I am liable for all
charges for services rendered and I agree to notify this doctor immediately whenever I have changes in my health
condition or health plan coverage in the future. I understand that my chiropractor or a clinic peer employed by ASH
Networks may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to
my chiropractor and/or ASH Networks to contact my physician if necessary.
Patient Signature: ___________________________________
Date: _____________________
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