Chiro-Associates Medical History Update

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• Patient Information

• First Name*
• Last Name*
• Date of Birth*
  
  Date Format: MM slash DD slash YYYY
  
• Has your address changed?
  • 
    Yes
  • 
    No
• Address*
• City*
• State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
• Zip*
• Email*
  
• Has your employment status changed?
  • 
    Yes
  • 
    No
• Employment Status
  • 
    Employed, New Job/Position
  • 
    Unemployed
  • 
    Retired
  • 
    Other

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• Employment Information

• Employer*
• Occupation*
• Address of Employer*
• City*
• State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
• Zip*
• Has your insurance information changed?
  • 
    Yes
  • 
    No

• Insurance Information

• Same as Patient Info
  • 
    Same as Patient Info
• First Name of Insured*
• Last Name of Insured*
• Insured's Date of Birth*
  
  Date Format: MM slash DD slash YYYY
  
• Relationship to Patient
• Insurance Company*
• I.D. Number*
• Signature*
• Your Name
• Date
  
  Date Format: MM slash DD slash YYYY
  
• Parent/Guardian Name (for patients under 18 years of age)*

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• Describe Your Symptoms

• Check if you are experience any of the following:
  • 
    Numbness
  • 
    Burning
  • 
    Stabbing
  • 
    Tingling
  • 
    Dull Ache

• Numbness

• Indicate where you feel numbness.
  • 
    Head
  • 
    Neck
  • 
    Mid-Back
  • 
    Lower-Back
  • 
    Other
• 
• 
• 
• Please Explain
• Rate Your Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

  10 being the worst

• Are your symptoms a result of:
  • Motor Vehicle Accident
  • Work Related Accident
  • Cause Unknown
  • Other
• How often do you experience your symptoms?
  • Constantly (76-100% of the day)
  • Frequently (51-75% of the day)
  • Occasionally (26-50% of the day)
  • Intermittently (0-25% of the day)

• Burning

• Indicate where you feel burning.
  • 
    Head
  • 
    Neck
  • 
    Mid-Back
  • 
    Lower-Back
  • 
    Other
• 
• 
• 
• Please Explain
• Rate Your Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

  10 being the worst

• Are your symptoms a result of:
  • Motor Vehicle Accident
  • Work Related Accident
  • Cause Unknown
  • Other
• How often do you experience your symptoms?
  • Constantly (76-100% of the day)
  • Frequently (51-75% of the day)
  • Occasionally (26-50% of the day)
  • Intermittently (0-25% of the day)

• Stabbing

• Indicate where you feel stabbing.
  • 
    Head
  • 
    Neck
  • 
    Mid-Back
  • 
    Lower-Back
  • 
    Other
• 
• 
• 
• Please Explain
• Rate Your Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

  10 being the worst

• Are your symptoms a result of:
  • Motor Vehicle Accident
  • Work Related Accident
  • Cause Unknown
  • Other
• How often do you experience your symptoms?
  • Constantly (76-100% of the day)
  • Frequently (51-75% of the day)
  • Occasionally (26-50% of the day)
  • Intermittently (0-25% of the day)

• Tingling

• Indicate where you feel tingling.
  • 
    Head
  • 
    Neck
  • 
    Mid-Back
  • 
    Lower-Back
  • 
    Other
• 
• 
• 
• Please Explain
• Rate Your Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

  10 being the worst

• Are your symptoms a result of:
  • Motor Vehicle Accident
  • Work Related Accident
  • Cause Unknown
  • Other
• How often do you experience your symptoms?
  • Constantly (76-100% of the day)
  • Frequently (51-75% of the day)
  • Occasionally (26-50% of the day)
  • Intermittently (0-25% of the day)

• Dull Ache

• Indicate where you feel dull aches.
  • 
    Head
  • 
    Neck
  • 
    Mid-Back
  • 
    Lower-Back
  • 
    Other
• 
• 
• 
• Please Explain
• Rate Your Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

  10 being the worst

• Are your symptoms a result of:
  • Motor Vehicle Accident
  • Work Related Accident
  • Cause Unknown
  • Other
• How often do you experience your symptoms?
  • Constantly (76-100% of the day)
  • Frequently (51-75% of the day)
  • Occasionally (26-50% of the day)
  • Intermittently (0-25% of the day)

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• Recent Symptoms/Pain

• How are your symptoms changing?
  • Improving
  • Unchanged
  • Getting Worse
• In general, are your symptom(s) better in:
  • AM
  • Midday
  • PM
• In general, are your symptom(s) Worse in:
  • AM
  • Midday
  • PM
• Do you have night pain unrelated to movement:
  • Yes
  • No
• Do you have constant pain unrelated to movement:
  • Yes
  • No

• My pain interferes with Daily Activities

  Choose the effect of the current condition of your ability to perform the following tasks

• Bending
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Kneeling
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Climb Stairs
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Lifting
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Driving
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Extended Computer Use
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Household Chores
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Reading (Concentration)
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Self-Care Bathing
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Self-Care Dressing
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Sleep
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Changing Position (Sit-Stand)
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Static Sitting
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Static Standing
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Walking
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Yard Work
  • No Effect
  • Mild/Painful (Can Do)
  • Mild/Painful (Limited)
  • Severe/Unable to Perform
• Occupational Activities
  • Administration
  • Business Owner
  • Clerical/Secretary
  • Computer User
  • Heavy Equipment Operator
  • Daycare/Childcare
  • Medium Manual Labor
  • Manufacturing
  • Home Services
  • Heavy Manual Labor
  • Light Manual Labor
  • Executive Legal
  • Housekeeper
  • Other

  Check the one that best describes your job describes your job description.

• Describe
• Condition's Effect On Job Performance
  • No Effect
  • Mild (painful can do)
  • Moderate (painful limited ability)
  • Moderate/Severe (limited duty)
  • Severe (can not work)

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• Physical Status

• Your Height*Under 4'0"4'0"4'1"4'2"4'3"4'4"4'5"4'6"4'7"4'8"4'9"4'10"4'11"5'0"5'1"5'2"5'3"5'4"5'5"5'6"5'7"5'8"5'9"5'10"5'11"6'0"6'1"6'2"6'3"6'4"6'5"6'6"6'7"6'8"6'9"6'10"6'11"Over 6'11"
• Weight (lbs)*
• Have you ever experienced major weight gain or loss?*
  • Yes, within the last 3 years.
  • Yes, more than 3 years ago.
  • No
• Do you ever experience low energy?*
  • Often
  • Sometimes
  • Rarely
  • Never
• Do you ever have difficulty sleeping?*
  • Often
  • Sometimes
  • Rarely
  • Never
• Are you currently pregnant?
  • Yes
  • No
  • Unsure

• Section Break

• Exercise Routine*
  • None
  • Moderate (2-3 days per week)
  • Daily
  • Heavy
• Effects of Current Condition on Performance*
  • No Effect
  • Mild/Painful (Can do)
  • Moderate/Painful (limited)
  • Severe/Unable to Perform

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• Signature*
• Name
• Date
  
  Date Format: MM slash DD slash YYYY
  
• Parent/Guardian Signature*
• Parent/Guardian Name*
• Date
  
  Date Format: MM slash DD slash YYYY
  

Save and Continue Later