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Reactivation Patient Paperwork

Reactivation Patient Paperwork Form

REACTIVATION PATIENT PAPERWORK
Today's Date*
MM
DD
YYYY
Patient Name*
First Last
Patient Birth Date*
Date Format: MM slash DD slash YYYY
Patient Age*
Patient Gender*
- Male
- Female
Patient Marital Status*
- Single
- Married
- Divorced
- Widowed
Patient Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Cell Phone*
(Or guardian's cell if patient is a minor)
Home Phone
Work Phone
Email
(Or guardian's email if patient is a minor) *Required because we will email all your scans and evaluation results to you after your initial reactivation appointment.*
Check the box ONLY if you do not have an email.
(For children, enter parent/guardian's email above)
- I do not have an email
Occupation*
(For minors who do not have an occupation, put "child")
Emergency Contact Name*
First Last
Emergency Contact Phone 1*
Emergency Contact Phone 2
Emergency Contact Employer
How were you referred to our office?*
- Online Search
- Social Media
- Walk-in
- Referral
- Other
Who can we thank for referring you to our office?
Please let us know how you heard about our office below.
PURPOSE OF THIS VISIT
Is this purpose related to an auto accident or work injury?*
- Yes
- No
When did the accident or injury occur?
Date Format: MM slash DD slash YYYY
Reason for this visit - Main Complaint*
Check the box ONLY if you are Not here because of pain/injury/etc.
(Check only if your reason above is for general health/wellness care/etc.)
- I am not here because of pain/injury etc. but to maintain a strong, healthy, spine for life
When did this condition begin?
Date Format: MM slash DD slash YYYY
Did it begin gradually, suddenly or progress over time?*
- Gradual
- Sudden
- Progressive over time
- N/A
What activities aggravate your symptoms?*
Is there anything, which has relieved your symptoms?*
- Yes
- No
- N/A
Describe what has provided relief
Type of Pain*
- Select All
- Sharp
- Dull
- Ache
- Burn
- Throb
- Spasm
- Other
- N/A
Please Explain:
Does the Pain Radiate into your:*
- Arm
- Leg
- Other
- Does not radiate
Please Explain:
Is this condition getting worse?*
- Yes
- No
How often do you experience these symptoms throughout the day?*
- 100%
- 75%
- 50%
- 25%
- 10%
- Only with activity
- Hardly ever/Never
Does complaint(s) interfere with:*
- Work
- Sleep
- Hobbies
- Daily Routine
- Other
Explain:
Have you been seen for this condition?*
- Yes
- No
How was it treated?
*Put "N/A" if not applicable
How did you respond to treatment?
*Put "N/A" if not applicable
SYMPTOMS QUESTIONNAIRE
Please select symptoms you're experiencing.*
This section is focused on misalignment of the neck region.
- Headaches
- Nervousness
- Insomnia
- Head Colds
- High Blood Pressure
- Migraine Headaches
- Nervous Breakdowns
- Amnesia
- Chronic Tiredness
- Dizziness
- Sinus Trouble
- Allergies
- Pain Around The Eyes
- Earache
- Fainting Spells
- Some Cases Of Blindness
- Crossed Eyes
- Deafness
- Neuralgia
- Neuritis
- Hay Fever
- Runny Nose
- Hearing Loss
- Adenoids
- Laryngitis
- Hoarseness
- Throat Conditions (sore throat or quinsy)
- Stiff Neck
- Pain in Upper Arm
- Tonsillitis
- Chronic Cough
- Croup
- Bursitis
- Colds
- Thyroid Conditions
- None of the above
Please select symptoms you're experiencing.*
This section is focused on misalignment of the mid-back region.
- Asthma
- Cough
- Difficulty Breathing or Shortness of Breath
- Pain in Lower Arms or Hands
- Functional Heart & Chest Conditions
- Bronchitis
- Pleurisy
- Pneumonia
- Congestion
- Influenza
- Gall Bladder Conditions
- Jaundice
- Shingles
- Liver Conditions
- Fevers
- Blood Pressure Problems
- Poor Circulation
- Arthritis
- Stomach Troubles or Nervous Stomach
- Indigestion
- Heartburn
- Dyspepsia
- Ulcers
- Gastritis
- Lowered Resistance
- Hives
- Kidney Troubles
- Hardening of the Arteries
- Nephritis
- Pyelitis
- Skin Conditions (acne, pimples, eczema or boils)
- Rheumatism
- Gas Pains
- Certain Types of Sterility
- None of the above
Please select symptoms you're experiencing.*
This section is focused on misalignment of the low back region.
- Constipation
- Colitis
- Dysentery
- Diarrhea
- Some Ruptures or Hernias
- Cramps
- Minor Varicose Veins
- Bladder Troubles
- Menstural Troubles (painful or irregular periods)
- Miscarriages
- Bed Wetting
- Impotency
- Change of Life Symptoms
- Knee Pain
- Sciatica
- Lumbago
- Difficulty urinating (includes frequent or painful urination)
- Backaches
- Poor Circulation in the Legs
- Swollen or Weak Ankles & Arches
- Cold Feet
- Weakness in the Legs
- Leg Cramps
- None of the above
Please select symptoms you're experiencing.*
This section is focused on misalignment of the pelvis.
- Sacro-iliac Conditions
- Spinal Curvatures
- Hemorroids
- Pruritis (Itching)
- Pain at the end of the spine while sitting
- None of the above
EXPERIENCE WITH CHIROPRACTIC CARE
Have you seen a chiropractor before?*
- Yes
- No
Who?
When did you last see them for care?
Date Format: MM slash DD slash YYYY
Give the Reason(s) for previous chiropractic visits:
Did you know posture determines your health?*
- Yes
- No
Are you aware of any poor posture habits?*
- Yes
- No
Explain:
Are you aware of any poor posture habits in your spouse or children?*
- Yes
- No
- N/A
Explain:
HEALTH LIFESTYLE
Do you exercise*
- Yes
- No
How often?
- Less than 1x per week
- 1x per week
- 2x per week
- 3x per week
- 4x per week
- 5 or more times per week
Do you smoke?*
- Yes
- No
How much do you smoke?
Do you drink alcohol?*
- Yes
- No
How many drinks per week?
Do you drink coffee?*
- Yes
- No
How many cups per day?
Do you take any health supplements (vitamins, minerals, herbs, etc.)?*
- Yes
- No
What kind and how often?
Please list any health conditions not mentioned above:*
*Put "N/A" if not applicable
Please list any medications you are currently taking and their purpose:*
*Put "N/A" if not applicable
Please list all past surgeries:*
*Put "N/A" if not applicable
Please list all previous accidents and falls:*
*Put "N/A" if not applicable
HEALTH INSURANCE
Will you be using health insurance for your chiropractic care?*
- Yes
- No
Name of Primary Carrier
Insured Date of Birth
Date Format: MM slash DD slash YYYY
Address of Insured
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Insurance ID#
Group#
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