| First Name: |
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| Last Name: |
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| Date of Birth: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Home Phone: |
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| Work Phone: |
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| Cell Phone: |
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| Email Address: * |
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| Business Employer: |
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| Name of Spouse: |
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| Spouse's Employer: |
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| Type of Work: * |
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| Referred to this office by: |
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| Choose one: |
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| Names and ages of children: |
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| What is you present complaint?: |
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| When and how did your problem begin?: |
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| Did this condition occur before?: |
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| Other doctors seen for this condition: |
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| Type of treatment: |
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| Results: |
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| Is the condition: |
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| Date of accident: |
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| Time of accident: |
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| Have you ever made a report of your accident to your employer?: |
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| What makes the problem better?: |
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| What makes the problem worse?: |
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| How would you describe the pain?: |
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| Other: |
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| How is your lifestyle being affected due to the pain?: |
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| What time is the pain most severe?: |
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| What time is the pain least severe?: |
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| How much does your pain affect your day to day activities?: |
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| Does pain radiate to other body parts? (Please, indicate left or right side): |
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| How often during awake time do you experience symptoms?: |
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| How bad is your pain or problem? where 1 = slight pain and 10 = unbearable?: |
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| Is there anything else you want the doctor to know?: |
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| Most patients that come to our office have one or two objectives in mind concerning their healthcare. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your doctor will weigh your needs desires when recommending your treatment program. Please check the type of care desired so that we may be guided by your wishes whenever possible: |
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| Today's Date: |
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| Your name: |
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