stcacupuncture.com - New Patient Form #2

PATIENT INTAKE FORM
Patient Name:
Date:

MonthDayYear
Date
1. Is today's problem caused by:

Auto AccidentWorkman's Compensation
2. Indicate on the drawings below where you have pain/symptoms
3. How often do you experience your symptoms?

Constantly (76-100% of the time)Occasionally (26-50% of the time)Frequently (51-75% of the time)Intermittently (1-25% of the time)
4. How would you describe the type of pain?

SharpNumbDullTinglyDiffuseSharp with motionAchyShooting with motionBurningStabbing with motionShootingElectric like with motionStiffOther
5. How are your symptoms changing with time?

Getting WorseStaying the SameGetting Better
6. Using a scale from 0-10 (10 being the worst), how would you rate your problem?

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst Pain
7. How much has the problem interfered with your work?

Not at allA little bitModeratelyQuite a bitExtremely
8. How much has the problem interfered with your social activities?

Not at allA little bitModeratelyQuite a bitExtremely
9. Who else have you seen for your problem?

ChiropractorNeurologistPrimary Care PhysicianER physicianOrthopedistMassage TherapistPhysical TherapistNo oneOther
10. How long have you had this problem?
11. How do you think your problem began?
12. Do you consider this problem to be severe?

YesYes, at timesNo
13. What aggravates your problem?
14. What concerns you the most about your problem; what does it prevent you from doing?
15. What is your:
Height
Weight
Age
Occupation
16. How would you rate your overall Health?

ExcellentVery GoodGoodFairPoor
17. What type of exercise do you do?

StrenuousModerateLightNone
18. Indicate if you have any immediate family members with any of the following:

Rheumatoid ArthritisDiabetesLupusHeart ProblemsCancerALS

19. For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column

	Past	Present
Headaches
High Blood Pressure
Diabetes
Neck Pain
Heart Attack
Excessive Thirst
Upper Back Pain
Chest Pains
Frequent Urination
Mid Back Pain
Stroke
Smoking/Tobacco Use
Low Back Pain
Angina
Drug/Alcohol Dependance
Shoulder Pain
Kidney Stones
Allergies
Elbow/Upper Arm Pain
Kidney Disorders
Depression
Wrist Pain
Bladder Infection
Systemic Lupus
Hand Pain
Painful Urination
Epilepsy
Hip Pain
Loss of Bladder Control
Dermatitis/Eczema/Rash
Upper Leg Pain
Prostate Problems
HIV/AIDS
Knee Pain
Abnormal Weight Gain/Loss
Ankle/Foot Pain
Loss of Appetite
Jaw Pain
Abdominal Pain
Joint Pain/Stiffness
Ulcer
Arthritis
Hepatitis
Rheumatoid Arthritis
Liver/Gall Bladder Disorder
Cancer
General Fatigue
Tumor
Muscular Incoordination
Asthma
Visual Disturbances
Chronic Sinusitis
Dizziness

Other:

For Females Only

	Past	Present
Birth Control Pills
Hormonal Replacement
Pregnancy

20. List all prescription medications you are currently taking:
21. List all of the over-the-counter medications you are currently taking:
22. List all surgical procedures you have had:
23. What activities do you do at work?
Sit:

Most of the dayHalf the dayA little of the day
Stand:

Most of the dayHalf the dayA little of the day
Computer work:

Most of the dayHalf the dayA little of the day
On the phone:

Most of the dayHalf the dayA little of the day
24. What activities do you do outside of work?
25. Have you ever been hospitalized?

YesNo
If yes, why
26. Have you had significant past trauma?

YesNo
27. Anything else pertinent to your visit today?
Patient Signature

Clear
Date:

MonthDayYear
Date
Should be Empty:

PATIENT INTAKE FORM