REASON FOR VISIT
The reason for visit (Please Circle): Work Accident Car Accident Trauma Chronic Pain Routine Adjustment
(Explain what happened):__________________________________________________________________________
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Please describe the pain & its location: ______________________________________________________________
When did condition begin? _____/_____/_____
Is this condition getting worse? __Yes __ No
Is the pain “constant” or does it “come and go”?________________
Is this condition interfering with your (Please Circle):
Work Sleep Daily Routine
If so, please explain: _____________________________________________________________________________
Have you had this or similar conditions in the past? __ Yes __ No
If so, please explain: _____________________________________________________________________________
Have you been treated by a Medical Physician for this condition? __ Yes __ No
If so, where? ___________________________________________________________________________________
Have you ever been treated by a Chiropractor before? __Yes __ No
If so, whom? ___________________________________________
Please mark areas of injury or discomfort. Mark all
areas with the appropriate symbols and indicate the
degree of pain using a scale from 1 (discomfort) to 10
(extreme pain).
Description –
Numbness – NN
Pins and Needles – PP
Burning – BB
Aching – AA
Stabbing – SS
Circle any area of pain not represented by a symbol.
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