Family First Chiropractic - Chiropractor In Sparks, NV, USA

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Home > New Patient Center > New Patient Submit email > Patient Intake Form

Patient Intake Form

Today's Date *

Patient First Name *

Patient Last Name *

Where are your area's of pain? *

How often do you experience your symptoms? *

Constantly (76-100% of the time) Frequently (51-75%of the time)Occasionally (26-50% of the time)Intermittently (1-25% of the time)

How would you describe the type of pain? *

SharpDullDiffuseAchyBurningShootingStiffNumbTinglySharp with motionStabbing with motionElectric like with motionOther: __________________________________

How are your symptoms changing with time? *

Getting worseStaying the sameGetting better

Using a scale from 0-10 (10 being worst), how would you rate your problem? *

012345678910

How much has the problem interfered with your work/school? *

Not at allA little bitModeratelyQuite a bitExtremely

How much has the problem interfered with your social activities? *

Not at allA little bitModeratelyQuite a bitExtremely

Who else have you seen for your problem? *

ChiropractorER physicianMassage TherapistNeurologistOrthopedistPhysical TherapistPrimary Care PhysicianNo OneOther: __________________________________

How long have you had this problem? *

How do you think your problem began? *

Do you consider this problem to be severe? *

YesYes, at timesNo

What aggrivates your problem? *

Always thereClimbing stairsPlaying golfSittingWhen under stressTurns over in bedWorking at a computerBendingCoughingPaintingSleepingUsing the phoneTravelingExercisingRiding a bikeDrivingPicking up a childSneezingPlaying tennisWalkingBreathing deeplyGoing down stairsRunningStandingThrowing a ballAt workOther: __________________________________

What alleviates the problem? *

Getting adjustedUseing heatLies on backDoes pilatesSwimmingDoing yogaUses analgesic creamUses iceGets massageRestsWarm bathPrescription medicationBends forwardLies face downUses muscle relaxorsStandsWalkingExercisesLies on sideTakes asprinStretchesUses orthoticsOther: __________________________________

What concerns you the most about your problem? *

Could be seriousIts getting worseIts affecting relationshipsIt is'nt going awayIts affecting work/schoolIts affecting mental outlookIts affecting leisure activitiesIts affecting golfOther: __________________________________

Height *

Weight *

Age *

How would you rate your overall health? *

ExcellentVery GoodGoodFairPoor

What type of excercise do you do? *

StrenuousModerateLightNone

Indicate if you have any immediate family members with any of the following: *

Rheumatoid ArthritisHeart ProblemsDiabetesLupusCancerALS

For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column.

Present *

HeadachesNeck PainUpper Back PainMid Back Pain Low Back Pain Shoulder PainElbow/Upper Arm PainWrist PainHand PainHip PainUpper Leg PainKnee PainAnkle/Foot PainJaw PainJoint Pain/StiffnessArthritisRheumatoid ArthritisCancer Chronic SinusitisAsthmaTumor High Blood Pressure Heart Attack Chest PainsStrokeAnginaKidney StonesKidney DisordersBladder InfectionPainful UrinationLoss of Bladder Control Prostate Problems Abnormal Weight Gain/LossLoss of AppetiteAbdominal PainUlcerHepatitisLiver/Gall Bladder DisorderGeneral FatigueDizzinessVisual DisturbancesMuscular IncoordinationDiabetesExcessive ThirstFrequent UrinationSmoking/Tobacco UseDrug/Alcohol DependenceAllergiesDepressionSystemic LupusEpilepsyDermatitis/Eczema/RashHIV/AIDSOther: __________________________________Birth Control PillsPregnancyHormonal Replacement

Past *

List all prescription medications you are currently taking:

List all over-the-counter medications you are currently taking:

List all surgical procedures you have had:

What activities do you do at work?

Sit:

Most of the dayHalf the dayA little of the day

Stand:

Most of the dayHalf the dayA little of the day

Computer Work:

Most of the dayHalf the dayA little of the day

On the phone:

Most of the dayHalf the dayA little of the day

What activities do you do outside or work?

Have you ever been hospitalized? If yes please explain:

Have you had significant past trauma? If yes please explain:

Anything else pertinent to your visit today?

Enter the verification code in the box below.

Verification Code: *

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