Danville Chiropractic Neurology Patient Intake Form (Page 2)
Give a brief detailed description of the problem you are currently
experiencing:_______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How long have you had this condition?________________ Is it getting worse?
yes
no______________________
Does it bother you (check appropriate box):
work
sleep
other:______________________________________
What seemed to be the initial cause:____________________________________________________________________
Please mark an area(s) of pain or altered sensation on the figure below.
P = Pain, N = Numbness, T = Tingling
Is there numbness, tingling or weakness present?
Yes
No
Please place a mark at the level
of your pain on the scale below:
Past Health History
Have you…
Yes No If yes, explain briefly
…been hospitalized in the last 5 years?
________________________
…had an x-ray in the last 5 years?
________________________
Had any broken bones?
________________________
Had any strains or sprains?
________________________
Ever seen a Chiropractor?
________________________
Do you get massage?
________________________
How is most of your day spent? standing, sitting other:_____________
Been in a motor vehicle accident? ______________________________
Have you had surgery (s)? __________________________________________
Family History
Habits
none light mod. heavy
Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Water
Advil etc.
Fast Food
Soda
If any blood relative has had any of the following conditions, please check and indicate which relative(s)
Alcoholism
Diabetes
Anemia
Emphysema
Arteriosclerosis
Epilepsy
Arthritis
Glaucoma
Asthma
Heart Disease
Cancer
High blood pressure
Do you have any other health issues or concerns we should be made aware of?
High cholesterol
Multiple sclerosis
Osteoporosis
Parkinson’s disease
Stroke
Thyroid disease
Danville Chiropractic Neurology
Patient Intake Form
Your responses are important to help us better
understand the health issues you are facing and
ensure the delivery of the best possible care.
All information provided is strictly confidential.
Danville Chiropractic Neurology
Dr. Christine M. Thompson
(925) 820-2167
390 Diablo Road, #230 Danville, CA 94526
danvillechiro@gmail.com or www.danvillechiro.com
Name: ____________________________________ Date: ___________
Insurance: __________________________________________________
Name of Primary Insured: _____________________________________
Date of Birth: _________________________
Male
Female
Address: _______________________________
Marital Status:
_______________________________________
S M P D W
_______________________________________ # of children _______
Your spouse’s date of birth:__________________________
Phone/Cell: ____________________ Home: _____________________
E-mail address: ______________________________________________
Occupation: ________________________________________________
Employer: __________________________________________________
Check X and indicate the age when you had any of the following for which you sought treatment:
General
Allergies
Anxiety
Depression
Dizziness
Fainting
Fatigue
Fever
Headaches
Loss of sleep
Nervousness
Tremors
Weight issues
Muscle / Joint
Arthritis
Bursitis
Foot/hand trouble
Muscle weakness
Low back pain
Neck pain
Mid back pain
Shoulder or hip pain
Skin
Boils
Bruise easily
Dryness
Hives or allergies
Itching
Rash
Varicose veins
Eye, Ear, Nose & Throat
Colds
Deafness
Ear ache
Eye pain
Gum trouble
Hoarseness
Nasal obstructions
Nose bleeds
Ringing of the ears
Sinus infection
Sore throat
Gastrointestinal
Abdominal pain
Bloody or tarry stool
Colitis / Crohn’s
Colon trouble
Constipation
Diarrhea
Difficult digestion
Diverticulitis
Bloated abdomen
Excessive hunger
Gallbladder trouble
Hernia
Hemorrhoids
Food Sensitivities
Jaundice
Liver trouble
Recurrent nausea
Painful bowel movement
Pain over stomach
Poor appetite
Vomiting
Vomiting of blood
Genitourinary
Bed wetting
Bladder infection
Blood in urine
Cloudy urine
Kidney infection
Kidney stones
Prostate trouble
Stress incontinence
Urination:
Overnight more than twice
More than 8x in 24hrs
Decreased flow / force
Painful urination
Urgency to urinate
Cardiovascular
High blood pressure
Low blood pressure
Hardening of the arteries
Irregular pulse
Pain over the heart
Palpitation
Poor circulation
Rapid heartbeat
Slow heartbeat
Swelling of ankles
Respiratory
Chest pain
Chronic cough
Difficulty breathing
Hay fever
Shortness of breath
Spitting up phlegm / blood
Wheezing
Women only
Dense breasts
Hot flashes
Lumps in breast
Menopause
Vaginal discharge
Menstrual flow
Reg.
Irreg.
Pain / cramps
Days of flow_____ Length of cycle_____
Date – 1st day last period: ___________
Are you pregnant? Yes,
No
If yes, how may months? ____________
Gestational diabetes
Birth control method: _______________
Date of last PAP test: ______________
normal,
abnormal
Date of last mammogram: __________
normal,
abnormal
Check any of the conditions
you have or have had:
Alcoholism
Anemia
Arteriosclerosis
Asthma
Bronchitis
Cancer
Chicken pox
Cold sores
Diabetes
Eczema
Edema
Emphysema
Epilepsy
Goiter
Gout
Heart burn / GERD
Heart disease
Hepatitis
Herpes
High cholesterol
HIV / AIDS
Influenza
Malaria
Miscarriage
Multiple sclerosis
Mumps
Numbness / tingling
Pace maker
Osteoporosis
Pneumonia
Polio
Rheumatic fever
Stroke
Thyroid disease
Tuberculosis
Ulcers
Please list any medications and/or supplements you are currently taking and why:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
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