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  • Healing Touch Chiropractic

    New Patient Intake
  • Demographics

  • Insurance Information

  • Pain/Injury Details

    Reason for Visit
  •  -  -
    Pick a Date
  • Auto Injury Information

  •  -  -
    Pick a Date
  • Health History

  • Review of System

    Have you EVER experienced any of the following?
  • Clear
  • Informed Consent

  • Please answer the following questions to help us determine possible risk factors

  • BONE WEAKNESS

    Toggle to "Yes" if the corresponding question applies to you.
  • VASCULAR WEAKNESS

    Toggle to "Yes" if the corresponding question applies to you.
  • SPINAL COMPROMISE OR INSTABILITY

    Toggle to "Yes" if the corresponding question applies to you.
  • Acknowledgements

  • Clear
  • SUMMARY ( FOR OFFICE USE ONLY) 

    General:

    The patient, a {age} year old {gender} presents to the clinic complaining of {whereDo}.  Symptoms began on {whenDid}. The pain is described as {howWould} and is {howOften}. The patient explains that symptims are{progressOf} since onset. 

    Patients Description of injury: {pleaseBriefly}

    Activities of daily living that are affected include: {activitiesOf}

    Prior Treatments: {whatTypes}

     

    Auto Injury (If Applicable):

    The patient, a {age} year old {gender} presents to the clinic complaining of {whereDo} as a result of an {whatBrings}.  Symptoms began on {whenDid}. The pain is described as {howWould} and is {howOften}. The patient explains that symptims are{progressOf} since onset. 

    The patient, a restrained {positionIn} of a {typeOf78} was {mechanismOf} by a {otherVehicle}. The patients vehicle was driving at approximately {howFast} while the opposing vehicle was traveling at approximately {howFast85}. The patient explains that the road conditions during the time of the accident was {whatWere} and occurred during {whatWere76}. 

    At the time of the accident, the patient exhibited feelings of {whatWere87}.  

    Activities of daily living that are affected include: {activitiesOf}

    Prior Treatments: {whatTypes}

    After the accident the patient went {whereDid} via {howWere}.  

    The patient description of the accident: "{brieflyDescribe}"

    Transported to Hospital/ER: {wereYou95}

    If so, which Hospital: {whichHospital}

    Imaging taken: {anyImaging}.  Findings: {whatWere93}

    Did you lose consciousness? {didYou}

    Did you hit your head?{didYou132} If so, Where: {whereDid130}

    Did you have any cuts/bruises? {didYou133}; If so where: {whereDo134} Stitches: {didYou135}

    Did you miss any days from school or work: {missAny}; if so How many? {howMany}

  • Should be Empty: