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CHIROPRACTIC

ADULT INTAKE

New Patient

Patient Information

Full Legal Name *

Nickname *

Date of Birth *

Gender

Male

Female

Phone *

Email *

Address *

City *

State *

Postal code *

Date *

Whom may we thank for referring you to us?

Is this injury/illness related to an automobile accident? *

Have you ever had Chiropractic Care before? *

Initial Problem Record

What is your main complaint or problem? *

How did this begin? *

When did this begin? *

Rate your complaint(s) today. If more than one complaint, fill in below: *

0 - None

1

2

3

4

5

6

7

8

9

10 - Worst

Complaint #2

Complaint #2 - When did this begin?

Complaint #2 - How did this begin?

Complaint #2 rating:

1 - None

2

3

4

5

6

7

8

9

10 - Worst

List Doctors (name & phone number or email) consulted for condition(s): *

What makes your problem better?

What makes your problem worse?

Has this happened before?

Yes
No
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List is empty.

This problem bothers me:

Occasionally (0%-25% of the time)
Intermittently (25%-50% of the time)
Frequently (50%-75% of the time)
Constantly (75%-100% of the time)
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List is empty.

Do you have any other related or unrelated complaints you would like to address?

Mark whichever number correlates to the area(s) of complaints on the graphic above

1 (R Head)

2 (L Head)

3 (Neck)

4 (R Chest)

5 (L Chest)

6 (Upper R Arm)

7 (Upper L Arm)

8 (R Arm)

9 (Left Arm)

10 (R Hand)

11 (L Hand)

12 (R Ribs)

13 (L Ribs)

14 (R Stomach)

15 (L Stomach)

16 (Groin)

17 (R Thigh)

18 (L Thigh)

19 (R Leg)

20 (L Leg)

21 (R Foot)

22 (L Foot)

23 (R Head Back)

24 (L Head Back)

25 (Neck Back)

26 (R Shoulder)

27 (L Shoulder)

28 (R Upper Arm Back)

29 (L Upper Arm Back)

30 (R Arm Back)

31 (L Arm Back)

32 (R Hand Back)

33 (L Hand Back)

34 (R Mid Back)

35 (L Mid Back)

36 (R Lower Back)

37 (L Lower Back)

38 (R Buttocks)

39 (L Buttocks)

40 (L Thigh Back)

41 (R Thigh Back)

42 (R Leg Back)

43 (L Leg Back)

44 (R Foot Heel)

45 (L Foot Heel)

Medical History and Present Medical Condition Questionnaire

Have you ever had any of the following conditions?

Allergies

Loss of hearing

Asthma

Kidney disease

Prostatitis

Colitis

Hepatitis

Liver disease

Elevated liver enzyme test

Pancreatitis

Heart murmur

Positive stress test

Heart valve abnormality

Heart failure

High cholesterol

High blood pressure

Arthritis/rheumatism

Thyroid trouble

Anemia

Eczema

Cancer (including skin cancer)

Sleep apnea

Ulcer

Heart attack

Loss of consciousness

Epilepsy

Convulsions/seizures

Stroke

Diabetes

Gastrointestinal

Vomited blood

Persistent diarrhea

Persistent constipation

Frequent abdominal pain

Frequent nausea

Frequent indigestion/heart burn

Black/bloody bowel movement

Hemorrhoids

Trouble swallowing

Hernia

Pulmonary

Shortness of breath

Chronic or frequent cough

Brown/blood-tinged sputum

Chest tightness

Wheezing

Heart/Vascular

Palpitation (irregular heartbeat)

Pain or discomfort in chest

High cholesterol

Swelling of feet

Leg pain while walking

Painful varicose veins

Musculoskeletal

Back trouble/pain

Neck trouble/pain

Joint injury/pain/swelling

Carpal tunnel syndrome

Eyes, Ears, Nose, Throat

Difficulty with night vision

Change in vision

Blurred/Double vision

Bleeding gums

Frequent nosebleeds

Recent hoarseness

Ringing/buzzing ears

Earaches

Miscellaneous

Bleeding/bruising easily

Enlarged glands

Rashes

Unexplained lumps

Chronic fatigue

Night sweats

Undesired weight loss

Snoring

Difficulty sleeping

Low blood sugar

Additional Health and Lifestyle Questions

Are you experiencing any stresses, mood problems, relationship difficulties, or substance-related problems for which you would like to resource or referral information on a confidential basis?

Yes
No
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If yes, please explain:

Please rate the following between 1-5, 1 being none and 5 being high, of your consumption of the following:

Alchohol
Water
Sugar
Dairy
Gluten
Processed Foods
Artificial Sweeteners
Cigarettes
Recreational Drugs

How many hours a day do you spend looking at the following:

Computer/Laptop
Cell phone
Television

Please rate the following between 1-5, 1 being none and 5 being high, of your feelings of stress about the following:

Home
Work
Life
Money
Health
Family

Would you consider yourself to have a well balanced diet? Please explain below if indicated.

Do you occasionally use or are you currently taking any prescription or over-the-counter medications?

Yes
No
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List name, dosage, and the reason for the medication:

Please describe any weekly exercise or physical activities including any exercise at work:

Trauma History

Have you ever been in an auto accident/fender bender?

Yes
No
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List is empty.

If yes, please describe nature of accident and age accident occurred:

Have you ever had any concussions/loss of consciousness?

Yes
No
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List is empty.

If yes, please describe nature of concussion/loss of consciousness and at what age:

Have you ever experienced any of the following? (Check all that apply):

Abusive relationship

Anxiety

Biking accident

Birth Trauma

Broken bones

Chemo/radiation

Child abuse

Contact sports

Depression

Given birth

Head injury

Medication injury

Miscarriage

Sexual assault

Death of loved one

Vaccine injury

None of the above

Have you ever had any surgeries? Please list below:

Signature *

Captcha

Brain, Not Bone Alone

Get in Touch

Phone: (970) 622-0075

Business Hours

Monday: 2pm-6pm

Tuesday: 8am-12pm, 2pm-6pm

Wednesday: 8am-12pm, 2pm-6pm

Thursday: 2pm-6pm

Friday: By special appointment only

Location:

2216 Hoffman Drive, Unit A,

Loveland, CO 80538

2216 Hoffman Dr unit a, Loveland, CO 80538, USA