Chiropractic Treatment Intake Form

Page 1

Date

Full Name

Nombre

Apellido

Birth Date

Phone Number

E-mail

Address

Dirección

Ciudad

Estado / Provincia

Código postal

1. Areas of discomfort/pain

2. Onset of discomfort/pain

4. Frequency

Constant Intermittent Occasional Only with movement

5. At what time of day is the pain at its worst?

Morning Afternoon Evening Night

6. Have you ever injured this area before?

7. Have you ever been in an accident (automobile, work, falls, etc.)?

8. List all related treatments received for this injury

9. Have you ever received therapeutic massage for a specific problem or injury?

10. Is there anything you do that creates, increases, or decreases pain?

11. What are the physical duties required of your occupation?

12. Are you currently seeing any other healthcare professional?

Please check any areas where you currently experience symptoms:

Shoulders Symptoms

Mid-Back Symptoms

Pain Stiffness Muscle Spasm None

Hip Symptoms

Pain Stiffness Limited Motion None

Make an Appointment

Date

Time

I certify that the information provided in this form is accurate and complete.

Signature

Sign here