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*
Zip*
Has Your Employment Status/Employer Changed
- Yes
- No
Employment Status
- Employed, New Job/Position
- Unemployed
- Retired
- Other
Employment Information
Employer*
Occupation*
Address of Employer*
City*
State*
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*
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

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Contact Us Today

Interested in learning more about our company and what we can do for your business? Complete the form below…

Step 1 of 5

Patient Information

Employment Information

Insurance Information

Describe Your Symptoms

Numbness

Burning

Stabbing

Tingling

Dull Ache

Recent Symptoms/Pain

My pain interferes with Daily Activities

Physical Status

Section Break

Contact Us Today