Name
Appointment Date
Appointment Time
 Please attach medical records as appropriate.
_______________________________________________________________________________________________
Concern (Please rank by priority)
Example: (headaches)
Onset
(June 1978)
Frequency
(4 times/wk)
Severity
mild/mod/severe
1.
2.
3.
4.
5.
6.
What are your goals for this visit? ______________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Pain Complaint: 1.___________________________
2. ___________________________
3.___________________________
Pins & Needles:
Burning:
Aching:
Stabbing:
Numbness:
Bladder/Bowel Changes?
YES
NO
Strength Change? Upper Extremity: YES NO Lower Extremity:
OOO
XXX
+++
///
----
YES
NO
What aspect of your pain, or which pain is the most bothersome to you?
__________________________________________________________________________________________________
Pain Intensity:
On a scale of 1-10 with “0” representing no pain, “1” representing a nuisance which would not interfere with daily
activities while “10” would be the most severe pain imaginable, which number best describes your pain?
What is your worst pain?
0 1 2 3 4 5 6 7 8 9 10
Overall average pain?
Less pain
0 1 2 3 4 5 6 7 8 9 10
What is your pain like today?
0 1 2 3 4 5 6 7 8 9 10
How many extremely bad days (horrible or excruciating pain) in a week do you experience?
1
More pain
_________
Check the box which best gives the intensity of your type of pain:
1. Sharp
2. Shooting
3. Throbbing
4. Cramping
5. Stabbing
6. Gnawing
7. Hot Burning
8. Aching
9. Heavy
10. Tender
11. Splitting
12. Tiring/Exhausting
13. Sickening
14. Fearful
15. Punishing/Cruel
Mild
Moderate
Severe
Unbearable
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Location
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
How much time during an average day (24 hour period) are you in pain?
 Pain is not present daily
 Almost 2/3rds of the time
 Less than 1/3 of the time
 Almost 24 hours
 Almost 50% of the time
 Anytime that I am not laying down
Do any of the following make your pain change?
No
Change
1. Sitting
2. Standing
3. Walking
4. Bending forward
5. Bending backward
6. Bending to same side
7. Bending to opposite side
8. Lying Down/Resting
9. Driving
10. Lifting
11. Coughing/Sneezing
12. Cold weather
13. Damp weather
14. Sexual activity
15. Overhead activity
16. Other
Somewhat
Worse
A Lot
Worse
Somewhat
Better
Complete
Relief
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_________________________________________________________________
2
Are you able to perform any of the following without assistance?
1.
2.
3.
Walk
Sit
Stand
 Yes
 Yes
 Yes
 No
 No
 No
4. Climb Stairs
5. Dress Self
6. Drive Car
 Yes
 Yes
 Yes
 No
 No
 No
Please mark the box which best describes the changes in your desire to participate in the following activities since the
onset of your pain?
No
Decreased
Decreased
Increased
Change
Some
Quite a Bit
Disappeared
Personal Hygiene
Household cleaning
Family activities
Recreation and hobbies
Sexual relations
Physical exercise
Watching television
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How often do you have to stop your activities and sit down or lie down to control your pain?
 Rarely (not daily)
 Approximately once a day
 I spend almost all day lying or sitting down to control my pain
 Several times a day
Sleep Pattern
1.
2.
3.
4.
5.
6.
Has your sleep pattern changed due to pain?
 Yes  No
Do you have trouble falling asleep?
 Yes  No
How many times do you wake up at night?
__________
How many nights a week? _________
How many hours do you actually sleep?
__________
How do you feel when you wake up in the morning? ______________________________________________
Do you take sleep aids?
 Yes  No
If so, what?
_________________________________
Previous treatments for this pain complaint and where:
 Chiropractor ___________________________
 Physical Therapy ______________________________
 Psychotherapy ___________________________
 Epidurals __________________________________
 Nerve Blocks ___________________________
 Cortisone Injections ____________________________
 Oral Cortisone ___________________________
 Operations____ _______________________________
 Other _____________________________________________________________________________________
Previous Studies:
 X-Rays
 CT Scan
 MRI
 Myelogram
 Bone Scan  Nerve Conduction Study
 Other _____________________________________________________________________________________
Prior experiences you have had with alternative medicine? _________________________________________________
__________________________________________________________________________________________________
Are you involved with any other therapies such as massage, acupuncture, chiropractic now? Previously?
__________________________________________________________________________________________________
3
What medications are you taking now? (Include prescription and over-the-counter drugs)
Medication
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
Reason
_______________
_______________
_______________
_______________
_______________
_______________
_______________
Medication Side Effects:
Constipation
When Started
________________
________________
________________
________________
________________
________________
________________
Swelling
Sweating
Dosage per Day
________________
________________
________________
________________
________________
________________
________________
Sleepiness
Cost
___________
___________
___________
___________
___________
___________
___________
Other: _______________
Allergic reactions to medications
Medication
_________________________________________
_________________________________________
_________________________________________
Reaction/Intolerances
___________________________________________________
___________________________________________________
___________________________________________________
Allergic reactions to chemicals/substances
Chemical/Substance
_________________________________________
_________________________________________
_________________________________________
Reaction/Intolerances
___________________________________________________
___________________________________________________
___________________________________________________
What vitamins/mineral/supplements are you taking now?
Brand or Other Name
(manufacturer)
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
Reason
When Started
Dosage per Day
Cost
_______________
_______________
_______________
_______________
_______________
_______________
_______________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
___________
___________
___________
___________
___________
___________
___________
What physical activity do you participate in? _____________________________________________________________
__________________________________________________________________________________________________
What are the major stressors in your life? _______________________________________________________________
__________________________________________________________________________________________________
What do you do to relax? _____________________________________________________________________________
__________________________________________________________________________________________________
Past Operations
What
_______________________
_______________________
_______________________
_______________________
When
___________________
___________________
___________________
___________________
What
________________________
________________________
________________________
________________________
4
When
__________________
__________________
__________________
__________________
Past Family Medical History
Father
Mother
Grandparents
Siblings
Children
Heart Disease
 _____
 _____
 _________
_____
_____
Hypertension
 _____
 _____
 _________
_____
_____
Cancer
 _____
 _____
 _________
_____
_____
Diabetes
 _____
 _____
 _________
_____
_____
Lung Disease
 _____
 _____
 _________
_____
_____
Hepatitis
 _____
 _____
 _________
_____
_____
Digestive
 _____
 _____
 _________
_____
_____
Seizures
 _____
 _____
 _________
_____
_____
Thyroid Disease
 _____
 _____
 _________
_____
_____
Other _____________
 _____
 _____
 _________
_____
_____
Other _____________
 _____
 _____
 _________
_____
_____
Other _____________
 _____
 _____
 _________
_____
_____
Occupation
_________________________________________________________________________________________________
Are you presently working?
Yes

No 
What interests/hobbies do you have? _________________________________________________________________
With whom do you live? (Include roommates, friends, partner, spouse, children, parents, relatives, pets)
Name
______________________
______________________
______________________
______________________
Age
____
____
____
____
Relationship
________________
________________
________________
________________
Name
_________________
_________________
_________________
_________________
Tobacco
 Never used
 Smoked from age _____ to ____.
Alcohol
 Never used
 Estimated drinks per day ____.
Other Drugs
 Never used
 Frequency ____.
Age
___
___
___
___
Relationship
___________________
___________________
___________________
___________________
____ packs per day.
What other things would you like us to know? ___________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Who would you like us to send a consultation report to? ___________________________________________________
__________________________________________________________________________________________________
5
REVIEW OF SYSTEMS
Check symptoms you currently have.
GENERAL
RESPIRATORY
MUSCLE/JOINT/BONE
BLEEDING PROBLEMS
❑ Chills
❑ Depression/Nervousness
❑ Dizziness/Fainting
❑ Fever
❑ Forgetfulness
❑ Headache
❑ Loss of sleep
❑ Loss of weight
❑ Numbness
❑ Sweats
❑ Shortness of breath
❑ Wheezing
❑ Short winded at rest
❑ Short winded w/activity
❑ Chest pain with breathing
Pain, Weakness/Numbness:
❑ Neck ❑ Chest
❑ Arms ❑ Hands
❑ Back ❑ Shoulders
❑ Hips ❑ Knees
❑ Legs ❑ Feet
❑ On blood thinners
❑ On platelet inhibitors
❑ Free bleeding with injury
❑ Known anemia
ENDOCRINE
❑ Excessive eating
❑ Excessive drinking
CARDIOVASCULAR
❑ Chest pain
❑ High/Low blood pressure
❑ Irregular/Rapid heart beat
❑ Poor circulation
❑ Swelling of ankles
❑ Varicose veins
NERVOUS SYSTEM
❑ Numbness
❑ Tingling
❑ Upper extremities
❑ Lower extremities
❑ Convulsions
❑ Falls/near falls
❑ Clumsiness
GASTROINTESTINAL
ALLERGY & IMM
❑ Allergic rhinitis
❑ Sensitivity to dander/
pollen/food
❑ Hives
EYE, EAR, NOSE, THROAT
❑ Bleeding gums
❑ Blurred vision
❑ Crossed eyes
❑ Difficulty swallowing
❑ Double vision
❑ Earache/Ear discharge
❑ Hay fever
❑ Hoarseness
❑ Loss of hearing
❑ Poor appetite
❑ Bloating
❑ Bowel changes
❑ Constipation
❑ Diarrhea
❑ Excessive thirst
❑ Gas
❑ Hemorrhoids
❑ Indigestion
❑ Nausea
❑ Rectal bleeding
❑ Stomach pain
❑ Vomiting
❑ Vomiting blood
PHYSCHIATRIC
❑ Anxiousness
❑ Stress
❑ Depression
❑ Suicidal thought
❑ Alcohol/Drug abuse
❑ Insomnia
❑ Memory loss
SKIN
❑ Bruise easily
❑ Hives
❑ Itching/rash
❑ Change in moles
❑ Scars
❑ Sore that won't heal
Check if you have had in the past or presently have any of the following conditions:
❑ Appendicitis
❑ Diabetes
❑ Liver Disease
❑ Arthritis
❑ Emphysema
❑ Measles
❑ Asthma
❑ Epilepsy
❑ Migraine Headaches
❑ Bleeding Disorders
❑ Glaucoma
❑ Multiple Sclerosis
❑ Cancer
❑ Heart Disease
❑ Mumps
❑ Cataracts
❑ Hepatitis
❑ Pacemaker
❑ Chemical Dependency
❑ Herpes
❑ Pneumonia
❑ Chicken Pox
❑ Kidney Disease
❑ Polio
6
GENITO-URINARY
❑ Blood in urine
❑ Frequent urination
❑ Lack of bladder control
❑ Painful urination
❑ Scars
❑ Sore that won't heal
MEN ONLY
❑ Erection difficulties
❑ Lump in testicles
❑ Penis discharge
❑ Sore on penis
❑ Prostate Problems
❑ Other
WOMEN ONLY
❑ Abnormal pap smear
❑ Bleeding between periods
❑ Breast lump
❑ Extreme menstrual pain
❑ Hot flashes
❑ Nipple discharge
❑ Painful intercourse
❑ Vaginal discharge
❑ Other
❑ Rheumatic Fever
❑ Scarlet Fever
❑ Stroke
❑ Thyroid Problems
❑ Tuberculosis
❑ Ulcers
❑ Venereal Disease, HCV,
HBV, HIV, Other