Patient Mailing Address
Have you had any chiropractic, physical, occupational/speech therapy, or home health in the last 12 months?
If yes, what treatment and when?
Motor Vehicle Accident
Is your injury due to a motor vehicle accident?
Work Related Accident (Workers' Compensation)
Is your injury due to a work related accident?
Are you still employed here?
Are you currently on work restriction?
Are you currently receiving any Home Health Services?
Have you received any aquatic therapy, physical therapy, speech therapy, and/or chiropractic services?
Was this injury work related?
If yes, is this being filed under:
Please list your diagnosis or involved area:
Have you had surgery due to your condition?
In the past year, have you fallen 2 or more times?
In the past year, have you fallen and sustained an injury?
If yes, are you taking oral medication or injections?
Have you abused alcohol or any illegal substances in the past 2 years?
Do you have any implants?
(i.e. Pacemaker, pins, plates, screws, prosthetic joint, etc)
Please tell us about your current symptoms
1. How did your symptoms start?
2. Have you been hospitalized for this problem?
3. What other treatment have you had for these symptoms?
4. My symptoms currently:
5. What tests have you had for these symptoms?
, X-rays, etc)
6. Do your symptoms change by?
7. How are you able to sleep at night due to your current symptoms?
9. Where is most of your pain located?
10. Rate your pain from 0‑10 for the following:
0 = no pain
10 = excruciating pain