Date_________ First Name __________________ MI___  Lasr Name________________________

Street Address _________________________ City____________________ State____ZIP ________

Birth Date _____ Sex ___ Age ____  Marital Status   M   D   W      SS#_____________________

Home Phone __________________ Cell __________________  Work Phone __________________

Email__________________________ Please print carefully Confidentiality Statement: All email addresses are used only by this office and are kept strictly confindential. We use them to confirm and make appointments. They will not be used by or sold to any person or company.

Occupation: ________________ Employer_________________ Address______________________

Emergency Contact:_______________________ Relationship_____________Phone____________

How Did you hear about our Office?   Internet ___ Dr. Referral ____ Friend or Family ___

Other ___________________________________________________________________________

What is your Current Complaint?

Chief Complaints: _________________________________________________________

_____________________________________________________________

When was the onset of this problem? (days, weeks, months, years)_____________________

Was the onset  ______gradual  ______ sudden _______ insidious

Drs. Consulted for this condion: _____________________________

How severe is the problem ?
___Mild ___Mild to moderate ___Moderate___Moderately Severe _____Severe

How frequent?  ___Constant___Occasiona____Intermittent_____Frequent

On a scale of 1-10, how would you rate your pain? 10-most painful - 1 least

1 2 3 4 5 6 7 8 9 10  (circle the number that corresponds to your pain)

Has there been any imporvement since the date of onset? ______________% 10-100

Select each choice that applies to you: 
Movement:
_____Cramps _____ Inflexibility _____ Restricted Movement ____ Spasm ____Stiffness
Sensation:
_____Crawling ____ Dead ____Numbness ___Pins & Needles ___ Prickly ___Tingling

Select the type of pain that best describes your complaint: ___achy ___ burning ___dull
Excruciating __ Numb ache ___ Pounding ___ Pulsating __ Sharp ___ Shooting ___Stabbing
___Stinging __-Throbbing

Is there any thing that makes you feel better? (heat, ice, stretching, medication, standing, sleep, nothing)
___________________________________________________________________________________

Is the pain usually better in the: ____ morning ___  druing the day ___at night?

Please indicate everything that makes you feel worse. (walking, bending, working, lifting)

___________________________________________________________________________________

Is the pain usually worse _____in the morning ___during the day ___ or worse at night?

Insurance Company (please present your card to reception)
Method of Payment ___Cash  ____ Check ____ Credit Card

Patient/Parent or Guardian signature_______________________________