Patient Intake Form - Vanderbilt Family Chiropractic
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3Vanderbilt Family Chiropractic
DATE_________________
NAME OF PATIENT:__________________________________________ BIRTH DATE:_____________
ADDRESS_______________________________CITY/STATE_______________________ZIP___________H
OME PHONE:_______________________________ CELL PHONE:______________________________
Email:_____________________________________ REFERRED BY:_______________________________
AGES OF CHILDREN:______________________ circle one:
SINGLE MARRIED DIVORCED WIDOWED
EMPLOYER:____________________________________JOB DESCRIPTION ______________________
WORK ADDRESS:________________________________________________________________________
WORK PHONE:______________________
INSURANCE PROVIDER:__________________________________________________________________
PRIMARY INSURED NAME:___________________________ INSURED’S BIRTHDATE: ___________
INSURANCE: GROUP #_______________________IDENTIFICATION #__________________________
CHIEF COMPLAINT:______________________________________________________________________
PATIENT EXPLANATION OF INCIDENT:___________________________________________________
____________________________________________________________________________________________
________________________________________________________________________________________
DATE OF ONSET:________________________ GRADUAL OR SUDDEN__________________________
ON THE JOB
YES
NO DAYS OFF WORK______________________________________________
AUTO ACCIDENT
YES
NO DAYS OFF WORK__________________________________________
LOCATION OF PAIN (INCLUDING EXTREMITY RADIATION)_______________________________
FREQUENCY/DURATION OF PAIN_________________________________________________________
SHARP, JABBING
ACHE
SEVERE
MODERATE
TYPE OF PAIN:
Other____________
PAIN
walking
standing
sitting
laying
WORSE IN
A.M. OR
P.M.
WHAT MAKES IT BETTER?_______________________________________________________________
OTHER CHIROPRACTORS CONSULTED________________________MD________________________
other__________
SLEEPING HABITS:
ON BACK
ON SIDE
SIDE W/ ARM EXTENDED
ON STOMACH
PREGNANT: YES or NO DATE OF LAST MENSTRUAL CYCLE:________________________________
MEDICAL HISTORY
ACCIDENT/INJURIES:____________________________________________________________________________
__________________________________________________________________________________________________
SURGERIES:________________________________________________________________________________________
_______________________________________________________________________________________________
MEDICATIONS/SUPPLEMENTS:______________________________________________________________________
_______________________________________________________________________________________________
EXERCISES:______________________________________________________________________________________
Additional patient record on file
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