GENERAL NEW PATIENT FORM
| REASON FOR VISIT - PAGE TWO |
HAVE YOU HAD PREVIOUS CHIROPRACTIC CARE? __________________________________________________________________
WHAT IS YOUR MAJOR COMPLAINT? _____________________________________________________________________________
OTHER COMPLAINTS: ___________________________________________________________________________________________
HOW DID CONDITION DEVELOP? ___________________________________________________________________________________
DATE OF ONSET: _______/_______/_______
HAVE YOU HAD SAME OR SIMILAR PROBLEMS IN THE PAST? __________
IS THIS CONDITION GETTING WORSE?
| __ |
YES
| __ |
NO
| __ |
CONSTANT
| __ |
COMES AND GOES
HOW LONG HAS IT BEEN SINCE YOU HAVE REALLY FELT GOOD? ___________________________________________________
WHAT AGGRAVATES CONDITION? ______________________________________________________________________________
DOES ANYTHING OFFER RELIEF? ________________________________________________________________________________
HOW WOULD YOU DESCRIBE DISCOMFORT?
| __ |
SHARP
| __ |
DULL
| __ |
ACHY
| __ |
THROBBING
WHAT PERCENT OF TIME DOES THIS CONDITION BOTHER YOU?
| __ |
0%
| __ |
25%
| __ |
50%
| __ |
75%
| __ |
100%
HOW WOULD YOU RATE THE LEVEL OF DISCOMFORT ON A SCALE OF 0 - 10 (0=NO PAIN 10=EXTREME PAIN)? ___________
OTHERS WHO HAVE TREATED YOU FOR THIS CONDITION?____________________________________________________________
