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Intake
Today's Date
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Patient's Name
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Age
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The Problem Which Brought You To The Doctor Today Is:
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Low Back Pain or Discomfort
Middle Back Pain or Discomfort
Neck Pain or Discomfort
Shoulder Pain or Discomfort
Upper Back Pain or Discomfort
Arm/Hand Pain or Discomfort
Abnormal Curvature of Back (e.g. Scoliosis)
Buttock Pain
Leg Pain
Discomfort on the Right Side
Discomfort on the Left Side
Right Side Arm/Leg
Ache
Numbness
Pins and Needles
Burning
Stabbing
Arm
Leg
Hand
Foot
Left Side Arm/Leg
Ache
Numbness
Pins and Needles
Burning
Stabbing
Arm
Leg
Hand
Foot
Back Pain
Ache
Numbness
Pins and Needles
Burning
Stabbing
Low Back
Mid Back
Upper Back
Neck Pain
Ache
Numbness
Pins and Needles
Burning
Stabbing
Shoulder Pain
Ache
Numbness
Pins and Needles
Burning
Stabbing
Hip Pain
Ache
Numbness
Pins and Needles
Burning
Stabbing
Pain Scale
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-- Please Select --
0
1
2
3
4
5
6
7
8
9
10
How Bad Is Your Low Back Pain?
-- Please Select --
0
1
2
3
4
5
6
7
8
9
10
How Bad Is Your Leg Pain?
-- Please Select --
0
1
2
3
4
5
6
7
8
9
10
How Bad Is Your Neck Or Upper Back Pain Now?
-- Please Select --
0
1
2
3
4
5
6
7
8
9
10
How Bad Is Your Arm Pain Now?
-- Please Select --
0
1
2
3
4
5
6
7
8
9
10
How Did Your Pain Begin?
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Injury On The Job
My Problem Is Chronic
I Don't Know
Date of Injury
Description of Injury
Previous Treatments
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Medications
Physical Therapy
Traction
Exercises
Injections
Chiropractic Care
Heat
Ice
Surgery
Other
Did You Receive Any Relief?
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-- Please Select --
Yes
No
I Have Had The Following Tests
Regular X-Rays
Discogram
CAT Scan
Myelogram
MRI
EMG
The Following Make My Back Discomfort Better
Heat
Ice
Bed Rest
Decreased Activity
Bending Forward
Bending Backwards
Other
Nothing Helps
The Following Make My Neck Discomfort Better
Heat
Ice
Bed Rest
Massage
Stretching/"Popping" Neck
Other
Nothing Helps
The Following Make My Back Discomfort Worse
Activity
Bending Forward
Bending Backward
Sitting
Standing
Walking
Sneeze/Cough/Straining to go to the Bathroom
Other
The Following Makes My Neck Discomfort Worse
Activity
Bending Neck Forward
Bending Neck Backward
Bending Neck To The Left
Bending Neck To The Right
Other
I Also Have The Following Problems
Specific Weakness of Muscles in My Arms and Hands
Generalized Weakness of Arms or Hands Due to Pain or Discomfort
Numbness
Tingling of Arms, Hands, Legs, Feet, Toes
Specific Weakness in legs
My Legs Fatigue or Hurt When I Walk Too Far
Trouble With My Bladder (Urine) Control
Trouble With Bowels
My Pain Is Worse At Night
My Pain Awakens Me From Sleep
Do You Have Problems Other Than Your Neck Or Back?
Eyes
Ears
Nose
Throat
Skin (Moles, Spots, Sores)
Unusual Lumps or Bumps Under the Skin
Shortness of Breath
Cough
Pain With Breathing
Sharp Chest Pain
Aching Chest Pain
Arm Discomfort Along With Chest Discomfort
Nausea/Vomiting
Stomach Pain
Diarrhea
Constipation
Bleeding in Bowel Movements
Black/Tarry Stools
Trouble With Legs
Fatigue With Walking That Is Relieved By Rest
Anxious/Fearful
Down/Depressed
I Am Abusing Drugs
I Have Abused Drugs
Ladies: Problems With Menstrual Period
Ladies: Vaginal Bleeding After Menopause
Ladies: Vaginal Discharge
Men: Problems With Sexual Function
Men: Discharge
Other Problems You Need to Discuss With The Doctor
Past Medical History
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Angina
Heart Attack
Heart Failure
Heart Murmur
Valve Disease
High Blood Pressure
Stroke
Stomach Ulcers
Duodenal Ulcers
Colon Ulcers
Diabetes (High Blood Sugar)
Hepatitis A/B/C
Cirrhosis
Kidney Stones
Kidney Infections
Emphysema
Tuberculosis
Chronic Bronchitis
Cancer
Frequent Pneumonia
Asthma
Anemia
Leukemia
Bleeding Tendency
Glaucoma
Degenerative Arthritis
Rheumatoid Arthritis
Gout
Cancer
Depression
Psychosis
Other
No Major Illnesses
Surgical History
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Tonsillectomy
Appendectomy
Gall Bladder
Hernia Repair
Males: Vasectomy
Hysterectomy
Prostate Operation
Biopsy
Fractures
Other
No Surgical History
Hospitalizations
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Major Injuries
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-- Please Select --
Auto or Cycle Accidents, etc.
No Major Injuries
Ladies: Menstrual History
Normal Periods
Menopausal
Post-Menopausal
Ladies: I Have Been Pregnant (Times)
1
2
3
4
5
More than 5
Ladies: I Have Had
Vaginal Deliveries
C-Sections
Ladies: Problems With Deliveries and Pregnancies
Childhood Diseases
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Rheumatic Fever
Other
Nothing Unusual
Marital Status
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-- Please Select --
Married
Separated
Divorced
Widow/Widower
Single
Number of Children
Occupation
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Alcohol Consumption
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Beer
Wine
"Hard" Drinks
None
Daily
Socially
I Honestly Consider Myself To Drink To Much
Others Think I Drink To Much
Tobacco Use
Cigarettes
Pipe
Cigars
None
Tobacco Use Frequency
Recreational Activities
Job Requirements
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Heavy Lifting (Over 60 lbs) With Frequent Bending and Stooping
Medium Lifting (30-50 lbs)
Light Lifting (10-20 lbs)
Sedentary (Sit Most Of The Time)
My Job Is Very Stressful; It Make Me Tense
Not Applicable
Family Medical History
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Stroke
Hypertension
Cancer
Diabetes
Heart Trouble
Lung Disease
Back Problems
Arthritis
Other
None
Allergies (If None List No Known Allergies)
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Medication List (Name, Dosage, Frequency, Reason For Taking)
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Electronic Signature
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* Required field
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