Adult Intake Name * First Name Last Name Date of Birth * Phone * (###) ### #### What cell service provider do you use? * Email * Address * What is your occupation? * Do you have children? * Yes No Marital Status * Single Married Widowed Divorced How did you hear about us? * Screening/Event Online Search Social Media Referral Other Please list the health concern that prompted your first visit: * Rate the severity: * (0=no pain, 10=unbearable pain) When did this problem begin? * Have you had this condition in the past? * Yes No Did this problem begin with an injury? * Yes No Is this problem constant or intermittent? * Constant Intermittent Please check any current or previous health concerns: * ADD/ADHD Allergies Anxiety Arm Pain Asthma Back Pain - upper Back Pain - mid Back pain - lower Chest Pain Chronic Fatigue Constipation Depression Disc Problems Dizziness Ear Infections Fibromyalgia Food Sensitivities Gastric Reflux Headaches Heart Disorder Hip Pain Infertility Irritable Bowel Knee Pain Leg Pain Lupus Menstrual Issues Migraines Neck Pain Nervousness Numbness in Arms/Hands Numbness in Legs/Feet Sciatica Shoulder Pain Sinus Issues Sleep Issues Skin Issues Stomach Disorders Throat Issues Thyroid Problems TMJ Ulcers Vertigo Arthritis Sexual Dysfunction Blood Pressure H/L Other Have you seen other doctors for these concerns? * Yes No If so, which type? Chiropractor Medical Doctor Other Location of pain (AREA OF MAIN CONCERN): * How would you rate your pain RIGHT NOW? * (0=no pain, 10=unbearable pain) What is your TYPICAL or AVERAGE pain? * (0=no pain, 10=unbearable pain) What is your pain level AT ITS BEST? * How close to "0" does your pain get at its best? What is your pain level AT ITS WORST? * How close to "10" does your pain get at its worst? Have you ever been involved in an auto accident? * Yes No If yes, when? Please describe any other traumas you have undergone: * Please check any condition you have currently, or have had in the past: Stroke Seizures Cancer Spinal Bone Fracture Heart Disease Scoliosis Spinal Surgery Diabetes Type 1/2 Please list all hospitalizations and surgical operations you have undergone within the corresponding year: * Please list all medications you are currently taking: * How would a change in your health positively impact your life? *Please be specific with the goals you are hoping to achieve through your care at our office. (i.e. 'I could work out again, I could play with my grandchildren, etc.') * Please identify any daily activities that are impacted by your health concerns: Lifting/Carrying Objects Sit to stand Climbing Stairs Driving Extended Computer Use Exercise Household Chores Lifting Children Dressing Sexual Activity Sleep Sitting Standing Work/Job Tasks Walking Washing/Bathing Yard Work Concentration (reading) Other Thank you! We look forward to meeting you!
