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We Create Healthy Families

Call us at (605) 275-5757 to make an appointment.

Adult

Adult Patient Intake Form







Male Female











Single


Married


Divorced


Widowed


Other







Existing Patient


Friend


Another Provider


Social Media


Radio Ad


Google Search


CURRENT HEALTH CONDITIONS




Suddenly


Gradually


Post Injury





Front of head Right side of head


Back of head Left side of head



Front of neck Right side of neck


Back of neck Left side of neck



Right mid back Central mid back


Left mid back


Right low back Central low back


Left low back


Abdomen Back of ribs


Chest Right side of ribs


Front of ribs Left side of ribs


Front of right upper extremity Front of Left upper extremity


Rear of right upper extremity Rear of Left upper extremity


Front of right shoulder Front of left shoulder


Rear of right shoudler Rear of Left upper shoulder


Front of right upper arm Front of left upper arm


Rear of right upper arm Rear of Left upper arm


Front of right elbow Front of left elbow


Rear of right elbow Rear of Left elbow


Front of right wrist Front of left wrist


Rear of right Wrist Rear of Left wrist


Front of right hand Front of left hand


Rear of right hand Rear of Left hand



Front of right lower leg Front of left lower leg


Rear of right lower leg Rear of left lower led


Front of right hip Front of left hip


Rear of right hip Rear of left hip


Front of right thigh Front of right knee


Rear of right thigh Rear of right knee


Front of left thigh Front of left knee


Rear of left thigh Rear of left knee


Front of right leg Front of right ankle


Rear of right leg Rear of right ankle


Front of left leg Front of left ankle


Rear of left leg Rear of left Ankle


Front of right leg Front of right ankle


Rear of right leg Rear of right ankle


Front of left leg Front of left ankle


Rear of left leg Rear of left Ankle


Top of right foot Top of left foot


Bottom of right foot Bottom of left foot


Right of right foot Right of left foot


Left of right foot Left of left foot




Yes No


Aching Sharp


Annoying Shock-like


Burning Shooting


Deep Stabbing


Diffuse Stiffness


Dull Throbbing


Heavy Tightness


Intolerable Tingling


Pulling OTHER


Gradual Insidious Recent Spontaneous Sudden Traumatic Unknown


Mild Mild to moderate Moderate Moderate to severe Severe


1 2 3 4 5 6 7 8 9 10

Least severe <------------------------------>Most severe


Constant Frequent Intermittent On and off Random Recurring


Employment


Homemaking


Social Life


Walking


Sitting


Standing


Sleeping


Lifting


Travelling or Driving


Personal Care


Almost any movement Love life


Athletic activity and/or exercise Lying down


Bathing Pulling


Bending Pushing


Caring for family Reaching


Carrying Reading


Changing positions Repetitive motions


Climbing stairs Resting


Computer use Running


Concentrating Self care(dressing, bathing, etc.)


Cooking Shaving


Coughing and/or sneezing Sitting


Daily Child or pet care Squatting


Driving Standing


Eating Stress


Falling or staying asleep Stretching


Getting in or out car Talking on telephone


Getting out of bed Turning


Getting up from lying down Twisting


Getting up from sitting Unknown


Grocery shopping Walking


Household chores Working


Lifting Yard work


Looking over shoulder OTHER



Nothing Prescription medication Chiropractic adjustment


Re-direct attention Cold packs


Excercise Rest


Heat packs Stretching


Massage Work


Over-the-counter medications OTHER


Physical therapy



None


Acupuncture Occupational therapy


Chiropractic care Osteopathic medicine


Craniosacral therapy Over-the-counter medications


Homeopathic medicine Physical therapy


Hypnosis Prescribed medications


Injection therapy Psychotherapy


Medical care Reiki


Naturopathic medicine Surgery


Nutritional supplements OTHER


Yes No Unsure


Yes No



Bending over Looking over shoulder


Caring for family Love life


Climbing stairs Lying down


Concentrating Reaching overhead


Dressing myself Rising out of chair or bed


Driving a car Showering or bathing


Excercising Sitting


Getting in/out of car Standing


Getting to sleep Staying asleep


Grocery shopping Using a computer


Household chores Walking


Lifting objects Yard work


REVIEW OF SYSTEMS



Yes No



TRAUMAS:Physical Injury History




Yes No




Yes No




Yes No




Yes No




None 1-2 x per week 3-6 x per week Daily




Back Side Stomach


Refreshed and ready Stiff and tired







FOR WOMEN ONLY


Yes No




Yes No




Yes No




Yes No




Yes No


TOXINS: Chemical & Environmental Exposure

Please rate your CONSUMPTION for each where 0 is none and 5 is high:




0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


THOUGHTS: Emotional Stresses & Challenges

Please rate your STRESS for each where 0 is none and 5 is high:




0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


YOUR HEALTH GOALS






CHIROPRACTIC HISTORY


Resolve existing condition(s) Overall wellness Both


Yes No



Pain Relief Physical Therapy & Rehab Nutritional Subluxation-based Other


PERSONAL HEALTH HISTORY






Yes No





INSURANCE & PAYMENT FOR CARE


Personal Insurance No Insurance Self Pay


Primary Insurance











AUTHORIZATION

I certify that I'm the patient listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment at the time services are rendered.