PATIENT INFORMATION Name Email Address Message Message Message State State State Name Name Can we call you at work Message Message Message Marital Status: Single Married Message Message Message Message Message Message Message Message Message Message Message Message Message Message Submit PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S) or CLAIM NUMBER SIGNATURE (X) DATE NAME Do you suffer from neck pain with pain in your shoulder, arms or hands? NO YES Comment Do you have weakness, numbness or burning in your shoulder, arms or hands? NO YES Comment Do your hands or arms fall asleep regularly? NO YES Comment: Do you have reduced feeling (sensation) or swelling in your hands or arms? NO YES Comment Do you suffer from a loss of handgrip strength? NO YES Comment Do you suffer from back pain with pain in your buttocks, legs or feet? NO YES Comment Do you have weakness, numbness or burning in your buttocks, legs or feet? NO YES Comment: Do our legs or feet fall asleep regularly? NO YES Comment Do you have reduced feeling (sensation) or swelling in your legs, feet? NO YES Comment Do you suffer from cold hands or feet? NO YES Comment: Do have frequent falls or find that you trip over your feet while walking? NO YES Comment . Do you suffer from headaches? If yes, how often, how severe, what has been tried? NO YES Comment: Medicines previously tried, dosage, duration and outcome. Advil Aleve Tylenol Steroids Prescriptions for a period of 0-3mos, 3-6mos, 6-12 mos. 12+mos Have you had an MRI? NO YES If yes: When? Who ordered it? What was it ordered for? Have you tried any Physical Therapy or Chiropractic treatments before? NO YES If yes: When? For how long? What kind? Have you used any splint or braces or other prescribed treatment by an MD? NO YES If yes: When? What kind? Who ordered it? Have you used any splint or braces or other prescribed treatment by an MD? NO YES If yes: When? What kind? Who ordered it? . If you have tried any treatment or medications, did this make your problem better? NO YES Comment Joint Pain or Weakness? Circle which applies. R Knee, L Knee, Bilateral Knees, L Hip, R Hip, Bilateral Hips, Shoulder, Elbows, Hands, Foot, Fingers NO YES Comment Submit Please mark Yes or No if you have had any of these symptoms within the last month. Neurological Migraines Yes Migraines No Headaches Yes Headaches No Slurring of Speech Yes Slurring of Speech No Ringing in Ear Yes Ringing in Ear No Ear/Nose/Throat Altered taste/smell Yes Altered taste/smell No Night Blindness Yes Night Blindness No Sore Throat Yes Sore Throat No Gingivitis Yes Gingivitis No Cardiovascular Chest Pain Yes Chest Pain No Palpitations-racing heart beat Yes Palpitations-racing heart beat No Swelling in hands/feet Yes Swelling in hands/feet No Anemia Yes Anemia No Respiratory Recurrent Respiratory Infections Yes Recurrent Respiratory Infections No Asthma Yes Asthma No Chest Congestion Yes Chest Congestion No Wheezing Yes Wheezing No GI (Gastrointestinal) Stomach Pains or Cramping yes Stomach Pains or Cramping No Constipation Yes Constipation No Reflux or Heartburn Yes Reflux or Heartburn No Bloating Yes Bloating No Gas Yes Gas No Nausea or Vomiting No Nausea or Vomiting No Musculoskeletal Joint Pain Yes Joint Pain No Arthritis Yes Arthritis No Chronic Pain Yes Chronic Pain No Muscle Aches Yes Muscle Aches No Submit Please mark Yes or No if you have had any of these symptoms within the last month. Skin Eczema Yes Eczema No Dermatitis Yes Dermatitis No Excessive Sweating Yes Excessive Sweating No Ringing in Ear Yes Ringing in Ear No Ear/Nose/Throat Altered taste/smell Yes Altered taste/smell No Night Blindness Yes Night Blindness No Sore Throat Yes Sore Throat No Gingivitis Yes Gingivitis No Cardiovascular Chest Pain Yes Chest Pain No Palpitations-racing heart beat Yes Palpitations-racing heart beat No Swelling in hands/feet Yes Swelling in hands/feet No Anemia Yes Anemia No Respiratory Recurrent Respiratory Infections Yes Recurrent Respiratory Infections No Asthma Yes Asthma No Chest Congestion Yes Chest Congestion No Wheezing Yes Wheezing No GI (Gastrointestinal) Stomach Pains or Cramping yes Stomach Pains or Cramping No Constipation Yes Constipation No Reflux or Heartburn Yes Reflux or Heartburn No Bloating Yes Bloating No Gas Yes Gas No Nausea or Vomiting No Nausea or Vomiting No Musculoskeletal Joint Pain Yes Joint Pain No Arthritis Yes Arthritis No Chronic Pain Yes Chronic Pain No Muscle Aches Yes Muscle Aches No Submit
