Launch Chiro_Neuropathy Consult ROF

Neuropathy Consult ROF
Please fill out the application entirely and legibly. We need all information for insurance purposes.
Name
Nickname
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
*We will need to contact you both by phone & email. Please be sure to give us the best phone number to reach you*
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Social Security
*If you have Medicare, we need you to list your SSN above or provide us with the Medicare card*
Spouse's Name
Spouse's Phone Number
Your Occupation
Retired?

YesNo
REVIEW OF SYMPTOMS
Please check all that apply

Foot PainDiabetesSpinal StenosisCancerPinched NerveHand PainHigh CholesterolDegenerative DiscChemotherapyPoor CirculationLow Back PainHigh Blood PressureVascular ProblemsArthritis in HandsJoint ReplacementNeck PainPacemaker/ DefibrillatorLeg PainArthritis in FeetFoot SurgeryFoot NumbnessHerniated DiscPlantar FasciitisImplanted Cord/ Bladder StimulatorPoor wound healingHand NumbnessBulging DiscMorton's NeuromaSciaticaExcessive thirst or urinationHand Numbness
PRESENT HEALTH CONDITION
In order of importance, list the health problems you are most interested in getting corrected:
1.
2.
3.
4.
List approximately how long you have noticed these problems:
1.
2.
3.
4.
Is there a certain time of day any of these problems are better or worse?
Is your balance/walking ability affected? If yes, please describe.
List the things you have used for these problems:

GabapentinNeurontinLyricaCymbaltaPhysical TherapyPain MedicationsAleveIbuprofenTylenolMortinChiropracticMassage TherapyInjectionsCreams
What do you think is causing your problem?
Name of all doctors you have seen for these problems and treatment you received.
Have your symptoms

ImprovedWorsenedStayed the same
List anything that makes your condition worse.
List anything that makes your condition better.
How would you describe the symptoms? Please check ALL that apply

Aching PainNumbnessHot SensationCrampingStabbing PainTinglingThrobbing PainSwellingSharp PainPins & Needles PainDead FeelingBurningTirednessHeavy FeelingCold Hands/FeetElectric Shocks
Is this condition interfering with any of the following?

SleepWorkDaily ActivitiesRecreational ActivitiesWalkingStanding
SOCIAL HISTORY
Do you smoke?

YesNo
If yes, how many cigarettes daily?
Do you drink?

YesNo
If yes, how many drinks per week?
Do you exercise regularly?

YesNo
If yes, please describe type & how often
CURRENT PAIN LEVELS
How would you rate your pain in the last week?

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst Pain
If you had to accept some level of pain after completion of treatment, what would be an acceptable level?

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst Pain
PREVIOUS HEALTH HISTORY

This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization, unless you sign here indicating that we can release copies by your verbal request.
Name
Signature

Clear
Please give name, address, and office phone number of your primary care physician.
Name
Phone
Address
When were you last seen there?
May we send them updates on your treatment/condition?

YesNo
List ALL allergies/sensitivities to medication, food, and other items here:
Item you react to
Reaction
List the prescription drugs you are currently taking (or you may attach a list):
Dose (mg or IU)
Times Daily
Please check mark if you will bring a medication list to the office

I will bring a physical medication list to the office
List the prescription drugs you are currently taking (or you may attach a list):
List all nutritional supplements (vitamins, herbs, homeopathics, etc) as above:
Dose (mg or IU)
Times Daily
Please check mark if you will bring a nutritional supplement list to the office

I will bring a physical nutritional supplement list to the office
List all nutritional supplements (vitamins, herbs, homeopathics, etc) as above:
Patient Quality of Life Survey Example
PRACTICE INFORMATION HERE

Patient Quaility of Life Survey
Name
Date

MonthDayYear
Date
Please take several minutes to answer these questions so we can help you get better. (Please check as many that apply)
1. How have you taken care of your health in the past?

MedicationsEmergency RoomRoutine MedicalExerciseNutrition/DietHolistic CareVitaminsChiropracticOther
2. How did the previous method(s) work out for you?

Bad resultsSome resultsGreat resultsNothing changedDid not get worseDid not work very longStill tryingConfused
3. How have others been affected by your health condition?

No one is affectedHaven't noticed any problemThey tell me to do somethingPeople avoid me
4. What are you afraid this might be (or beginning) to affect (or will affect)?

JobKidsFuture abilityMarriageSelf-esteemSleepTimeFinancesFreedom
5. Are there health conditions you are afraid this might turn into?

Family health problemsHeart diseaseCancerDiabetesArthritisFibromyalgiaDepressionChronic FatigueNeed surgery
How has your health condition affected your job, relationships, finances, family, or other activities? Please give examples:
What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) Give 3 examples:
What are you most concerned with regarding your problem?
Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specific
What would be different/better without this problem? Please be specific.
What do you desire most to get from working with US?
What would that mean to you?
Should be Empty:

Neuropathy Consult ROF

REVIEW OF SYMPTOMS

PRESENT HEALTH CONDITION

SOCIAL HISTORY

CURRENT PAIN LEVELS

PREVIOUS HEALTH HISTORY

Patient Quality of Life Survey Example