Irving Park Chiropractic Center - Fill Out Paperwork Online

Fill Out Paperwork Online

Patient Demographics

Today's Date:

First Name *

M.I.

Last Name *

Date of Birth *

Sex *

M

F

Sex at birth *

M

F

Address *

City *

State *

Zip Code *

Home Phone

Work Phone

Cell Phone *

Email Address *

Occupation

Employer

Are you, or may you be, pregnant?

Yes

No

Did you have any of your pain before the accident? * Yes No

If so, where was your pain?

History

What was the date of your accident? *

Were you (in/on) a: *

Car

Scooter

Bicycle

Pedestrian

Motorcycle

Rideshare

Other (Describe):

Please briefly describe how the accident happened: *

Do you have any pain, numbness or tingling traveling from your neck or back? * Yes No

If yes, describe what you feel.

Were you:
Passenger | Driver | N/A

Seatbelt worn?
Yes No

Airbags go off?
Yes No

Did you go to the hospital, urgent care, see any other medical provider or have any other treatment after the accident * Yes No

If yes, what hospital or urgent care? Were any scans taken? Yes No

If yes, were there any findings?

Was there any bruising to your body due to the accident? Yes No

If so, where?

Are you taking any pain medication due to the accident? Yes No

If so, what is the medication?

Did you miss any work due to the accident? Yes No

If yes: What is your job?

How much time have you missed?

History of spinal surgeries? Yes No

If yes, list year and type:

History of cancer? Yes No

If yes, kind, diagnosis date, and remission status:

Medical History

Neuromusculoskeletal history before your accident: * (select "None" if not applicable)

Stroke

Rheumatoid arthritis

Paralysis

Gout

Seizures

Lupus

Mental disorders

Osteoporosis

Fractures

Scoliosis

Dislocations

Change in vision, smell, hearing or taste

Orthopedic problems

Light headedness

Arthritis

Dizziness/vertigo

Loss of consciousness

Numbness or tingling

Difficulty speaking or swallowing

Difficulty walking

Headaches

Change in mood or behavior

None

Patient Consent

Digital Signature (Type your full name) *

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