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First Name *

Last Name *

Email Address*

Date of Birth *

Gender
MaleFemale

Address

Home Phone

Cell Phone

Work Phone

Occupation

Family Doctor

How did you find us?
Friend/Family MemberInsurance Provider DirectoryWebsiteLocationOther (please describe)

Additional Info (reference name, description, etc.)

Payment for Services will be
Self PayHealth InsuranceAuto AccidentWorkers Compensation

Are you, or might you be, pregnant?
NoYes

Date of last menstrual period

What are your present complaints?

When did they start?

What happened to cause these symptoms?

Where are you currently experiencing pain or other symptoms?
Lower BackNeckOther

What is your pain level?
012345678910

Symptoms are worse in
MorningNightAfternoonConstantCome and Go

Have you ever had this before?
NoYes

If so, when?

Name and location of doctors previously seen for present condition(s)

Please mark where your have pain

Pain Chart

What activities aggravate your condition?

What activities relieve your condition?

Please mark any additional symptoms you may be experiencing
Blurred visionCold HandsUpset StomachFacial FlushingFeverBuzzing in earsCold SweatsDizzinessFaintingHeadachesCold FeetConstipationDiarrheaFatigueInsomniaLight bothers eyesLoss of balanceLoss of smellLoss of tasteMuscle JerkingNumbness in fingersNumbness in toesRinging in earsShortness of breathStiff NeckPins and needles in armsPins and needles in legsConcentration loss / ConfusionDepression or weeping spellsHead seems too heavyLow resistance to colds

Do you have any allergies?
NoYes

If so, what kind?

Are you taking any medications?
NoYes

If so, what kind?

Have you been treated by a physician for any health condition in the last year?
NoYes

If so, describe condition

Date of last physical examination?

Surgical History

Surgery #1

Surgery #1 Date

Surgery #2

Surgery #2 Date

Surgery #3

Surgery #3 Date

Have you ever had a metal implant?
NoYes

List accidents you have been involved in

Accident #1 Type
jobAutoOther

Accident #1 Description

Accident #1 Date

Accident #2 Type
JobautoOther

Accident #2 Description

Accident #2 Date

Please indicate which PAST or PRESENT conditions have been experienced prior to present complaint by marking appropriate boxes.

AIDS
SelfMotherFather

Anemia
SelfMotherFather

Arthritis
SelfMotherFather

Asthma
SelfMotherFather

Back Pain
SelfMotherFather

Bladder Trouble
SelfMotherFather

Bone Fracture
SelfMotherFather

Cancer
SelfMotherFather

Chest Pain
SelfMotherFather

Concussion
SelfMotherFather

Convulsions
SelfMotherFather

Diabetes
SelfMotherFather

Indigestion
SelfMotherFather

Dislocated Joints
SelfMotherFather

Other Comments

Patient Consent

Patient Name*

Digital Signature*
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