Health History Intake
Fort Wayne Spine & Joint
Full Name
*
First Name
Last Name
Date Of Birth
*
/
Month
/
Day
Year
Date
Phone Number
Please enter a valid phone number.
Are you willing to receive text messages from our office?
*
Yes
No
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Past Medical History: Check all that apply and fill in any not listed at the end.
*
None
Allergies
Alzheimer's
Anemia
Anxiety
Arthritis
Asthma
Bleeding Disorder
Blood Clot(s)
Breast Disease
Broken Bone
Cancer
Chronic Fatigue
Chronic Pain
Chronic Sinusitis
Depression
Diabetes
Diarrhea
Diverticulitis
Eczema
Emphysema
Endometriosis
Epilepsy
Fibromyalgia
Gout
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
Hypothyroidism
Impotence
Irritable Bowels
Kidney Disease
Low Testosterone
Menopause
Migraines
Multiple Sclerosis
Osteoporosis
Panic Disorder
Prostate Enlargement
Reflux (GERD)
Seizures
Stroke
Urinary Tract Infection
Other
Family Medical History: To the best of your knowledge, have any blood relatives been diagnosed with the following:
*
None
Alcoholism
Allergies
Alzheimer's
Anemia
Asthma
Birth Defect
Bleeding Disorder
Cancer
Depression
Diabetes
Epilepsy
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Stroke
Other
Review of Symptoms: Check the symptoms that you have had in the past couple weeks.
*
None
Blurred Vision
Cardiac Disease
Cardiovascular
Chest Pain
COVID
Fatigue
Gastrointestinal
Genitourinary
Headaches
Joint Pain
Lightheaded/Dizziness
Lymphatic
Muscle Weakness
Neurological
Problems Falling Asleep
Problems Staying Asleep
Psychiatric
Respiratory
Stroke
Smoker
Weight Gain
Weight Loss
Other
Past Surgical History:
*
None
Appendix
Catheterization
C-Section
Gall Bladder
Tonsils
Sinus Surgery
Tubes In Ears
Hernia
Hysterectomy
Tubal Ligation
Cardiac Bypass
Spinal Fusion
Brain Shunt
Joint Replacement
Other
Medications: Please attach a separate list if you have one, or if you need extra space.
Do you have any allergies?
*
Yes
No
Occupation. Please list your employer, what you do, approximately how many hours per week and your level of satisfaction:
*
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
Please list drugs used:
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Who is your primary care physician?
*
What is your primary complaint?
*
(Please include side of body, etc.)
What best describes the nature of your pain?
*
Aching
Burning
Throbbing
Numbness
Pins & Needles
Tingling
Other
Please rate your pain level for primary complaint:
*
Less Pain
1
2
3
4
5
6
7
8
9
Extreme Pain
10
1 is Less Pain, 10 is Extreme Pain
How did your pain begin?
*
(Please be as specific as possible.)
How long have you had the pain?
*
(Please be as specific as possible.)
What percentage of time awake do you experience your pain?
*
(0-100%, 5% = rarely, 100% = constant pain)
What makes your pain BETTER?
*
Ice
Heat
Massage
Medications
Nothing Helps
Stretching
Other
What makes your pain WORSE?
*
Bending
Bowel Movements
Coughing
Daily Routine
Driving
Getting Up
Lifting
Lying Down
Pulling
Pushing
Reading
Sitting
Sleeping
Sneezing
Standing
Turning Head
Urination
Walking
Working
Other
What associated symptoms do you have?
*
None
Blurred Vision
Bowel/Bladder Issues
Dizziness
Ear Ringing
Headaches
Loss of Appetite
Nausea
Weight Loss
Other
What type of imaging have you had of the area?
*
None
X-Ray
MRI
CT Scan
Ultrasound
Other
Which office/hospital performed the imaging?
Please include year performed.
Have you been to a chiropractor before?
*
If yes, how long ago?
What are your goals for care?
*
Please explain.
Which treatment option are you MOST interested in for your care?
*
Manipulations/Adjustments
Muscle Work
Home Exercises
Acupuncture/Needling
Strengthening/Stretching
Pain Relief
Other
Who told you about our office?
*
Please be specific. If a friend told you about us, we want to thank them!
Which doctor do you prefer to see?
*
Dr. Troy Byall
Dr. Nathan Hiss
Dr. Ryan Hosler
No Preference/First Available
Who is your insurance carrier?
*
Please list the subscriber/member ID from your insurance card.
Signature
Submit
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