Patient Intake Form

Patient Name:________________________________________________  Date _________________________

1.  Is today's problem caused by: ____Auto Accident    ____Workman's Compensation

2.  How often do you experience your symptoms?  ___Constant (76-100% of time) __Frequent  (51-75% of time)   ___Occasionally (26-50% of time) ___Intermittant (1-25% of time)

3.  How would you describe the type of pain? (circle as many as needed)

Sharp  Dull Diffuse  Achy  Burning Shooting  Stiff  Numb  Tingly  Sharp with motion  Shooting with motion 

Stabbing with motion  Electric like with motion  Other ______________________________________________

4.  How are your symptoms changing with time? ___Worse  ___Staying the same  ___Better

5.  Using a scale from 0-10 (10 being the worst, how would you rate your problem?

               0     1     2     3     4     5     6     7     8     9     10 (please circle)

6.  How much has the problem interfered with your work?

    ___Not at all   ___A little bit     ___Moderately   ___Quite a bit    ___Extremely

7.  How much has the problem interfered with your social activities?

   ___Not at all  ___A little bit   ___Moderately  ___Quite a bit  ___ Extremely

8.  Who else have you seen for your porblem?

   __Chiropractor ___Neurologist ___Primary Care Physician ___ER physician  ___Orthopedist ___Massage Therapist

   ___Physical Therapist  ___No one  ___Other _____________________________________________

9.  How long have you had this problem? _____________________________________________

10.  How do you think your problem began? ________________________________________________________