Page 1 of 2 Health Review Form Intake Details Welcome, and thank you for choosing the Chiropractic Health Institute. Before we get started, we need a little information to see if you qualify for chiropractic care. These forms will take you around ten to fifteen minutes to complete. Name * First Name Last Name Today's Date: * MM DD YYYY Health Checklist We’d like to first get a sense of how you’re feeling to see if our care is the right fit for you. Please check any boxes that relate to your issue. Area Affected: * Select the primary area of concern. Head Neck Mid-back Low-back Between the shoulder blades Shoulder Elbow Wrist Hand Fingers Hip Thigh Knee Ankle Foot Toes No issues. I'm here for wellness. (Please check "none" or "no" for all of the questions below.) Other Specific Location: * In the affected area, where would you like the doctor to focus? Check all that apply: Upper Mid Lower Center (middle) Left side Right side Both sides Front (anterior) Back (posterior) None Other: What does the problem feel like most of the time and when it is at its worst? * Check all that apply: Aching Burning Dull (not sharp) Pain Radiating Sharp (like a knife) Shooting (like a quick pain) Stabbing Tingling (like pins and needles) Numbness (can't feel much) Soreness Spasm Stiffness Tension Tightness None Other: When the problem is at its worst, how bad is it at its worst? * 0 - No pain 1 2 3 4 5 6 7 8 9 10 - Severe/worst pain imaginable How often do you feel the pain/problem? * 0 - Never 1 2 3 4 5 6 7 8 9 10 - Constantly/all the time How frustrated are you with the pain/problem? * 0 - Not frustrated at all 1 2 3 4 5 6 7 8 9 10 - Extremely frustrated How serious do you feel the problem is? * 0 - Not serious at all 1 2 3 4 5 6 7 8 9 10 - Extremely serious How would you describe your emotional state related to this issue? * 0 - Completely calm 1 2 3 4 5 6 7 8 9 10 - Extremely distressed How many different types of remedies have you tried? * Check all that apply: Exercise Acupuncture CBD oil / cream Massage therapy Medication: over-the-counter (Aspirin, Advil, Aleve, Bayer, Excedrin, Motrin, Tylenol, Ibuprofen, etc.) Medication: prescription (Celebrex, Duragesic, Flexeril, Gabapentin, Muscle Relaxants, NSAIDs, Oxycodone, OxyContin, Neurontin, Percocet, Prednisone, Tramadol, Vicodin, Voltaren, etc. Medical care (doctor, emergency room, osteopath, physician, walk-in clinic, etc.) Rubs, creams, and gels (Ben Gay, Tiger Balm, Icy Hot, etc.) Physical therapy Pain patches Stretching None Other: Did any of the remedies provide relief? No Not really Somewhat Yes Not applicable How motivated are you to solve the problem? * What is your level of commitment to your health and healing? 0 - Not motivated at all 1 2 3 4 5 6 7 8 9 10 - Fully motivated/committed How did the problem start? * Check any way the condition might have started: Car accident Playing sports or exercising Doing the same thing over and over This is a worsening of a long term problem It came on by itself Falling down From my job I don't know None Other: When did the problem start? * If this problem started more than six months ago, tell us when it began to feel worse again. MM DD YYYY What makes the pain/problem better? * Sleep Sitting Standing Stretching Lying down Medication Movement Exercise Walking Rest None Other: What makes the problem worse? * Sleep Driving Standing Bending over Lying down Lifting something heavy Reaching for things Feeling stressed Turning around Twisting I don’t know None Other: Are there any other feelings associated with this problem? * Do you feel anything else with the issue? Check all that are true: Discomfort Numbness Pain going to other parts Soreness Spasm Stiffness Tension Tightness None Other Are there any other issues you would like to discuss with the doctor? * Yes No Health Review Next, please share information about your health history. Occupation Please check all symptoms you have experienced within the last month. Use OTHER to explain any symptoms that may not be listed. In each section, check NONE if you have not experienced any difficulties. If you have any questions, just let us know. Health in General (Constitutional) * Fever Chills Lack of energy Loss of appetite Sleep disturbances Heavy sweating/night sweats Unexplained weight loss or gain None Other: Heart & Blood Vessels (Cardiovascular) * Heart attack Racing heart Varicose veins Irregular heart beat Chest pain or discomfort Pain in the legs when walking Swelling of the arms or hands Swelling of feet, ankles or legs None Other: Kidney & Bladder (Genitourinary) * Painful urination Difficulty urinating Frequent urination Loss of urinary control (Female) PMS symptoms (Male) Prostate problems None Other Muscles, Bones, & Joints (Musculoskeletal) * Neck pain Back pain Joint pain Joint swelling Aching muscles Pain with walking Limitation of motion None Other: Skin, Hair & Breast (Integumentary) * Itching Skin rash Breast changes Lumps or masses Hair loss or increase Discoloration of the skin None Other: Brain & Nerves (Neurological) * Tremors Headache Dizzy spells Feeling weak Double vision Convulsions/seizure Uncontrolled motions Numbness or tingling Episodes of vision loss Problems with walking or balance None Other: Mood & Thinking (Psychiatric) * Anxiety Irritability Insomnia Depression Mood swings Hallucinations None Other: Blood & Lymph (Hematologic/Lymphatic) * Easy bruising Bleeding tendencies Swollen glands or unexplained swollen areas Bleeding for long periods of time/blood clotting problems None Other: Drugs (Medications) * Please identify all the drugs you are currently taking. Check all that apply or "None" if you are not using any: Analgesics/Opioid (e.g., Hydrocodone/Acetaminophen) – For pain relief. Analgesics/Over-the-Counter (e.g., Ibuprofen, Acetaminophen, Aspirin) – Used for pain relief, reducing inflammation, and fever management. Antidepressants (e.g., Sertraline, Fluoxetine, Citalopram) – Used to treat depression, anxiety, and other mood disorders. Blood Pressure – (e.g., Amlodipine, Lisinopril, Losartan, Metoprolol) Used to treat high blood pressure, angina, heart issues, and chest pain. Blood Thinners (Anticoagulants/Antiplatelets) (e.g., Warfarin, Apixaban, Clopidogrel) – Used to prevent blood clots, strokes, and heart attacks. Statins (e.g., Atorvastatin, Simvastatin) – Used to lower cholesterol. None Other: Previous surgeries and year: How often do you smoke? * Daily Weekly Monthly In the past Never How often do you drink alcohol? * Daily Weekly Monthly In the past Never Is there anything else which may help us to understand you, your history, or your needs that have not been discussed in this survey? * Yes No How did you hear about the office? * Family member Friend Facebook Google ad Physician / specialist Web search None Other Whom may we thank for referring you? Please click "Continue" to proceed to the final form. Thank you. Please let the receptionist know you have finished. Page 1 of 2
