Kennewick Chiropractic Injury Clinic

Patient Name

Sex

Marital Status

Pregnant

CONTACT INFORMATION

Contact Preference

Email

INSURANCE

Are you the policy holder?

Do you have Secondary Insurance?

If yes, please complete the following

PATIENT HISTORY

Have you ever received Chiropractic Care?

Please give a brief description of the problem(s) you are experiencing in order of severity

Are you seeing any other providers for other problems or health conditions?

PAST HISTORY

Do you smoke?

FAMILY MEDICAL HISTORY

Do you have a family history of: (Please indicate all that apply)

MEDICATIONS

ALLERGIES

The rating scale below is designed to measure how your condition affects your ACTIVITIES OF DAILY LIVING. On a scale of 0- 10 with 0 being no pain at all and 10 being the worst pain you’ve had.

Does your Condition cause any pain or restrictions while doing any of the following activities, please rate the following.

Which motion(s) is affected

Which motion(s) is affected

Which motion(s) is affected

Which motion(s) is affected

Cooking

Which motion(s) is affected

Cleaning

Which motion(s) is affected

Laundry

Which motion(s) is affected

Home Maintenance

Which motion(s) is affected

Landscaping (mowing lawn)

Which motion(s) is affected

Gardening

Which motion(s) is affected

Which motion(s) is affected

Ex

Method of payment for today’s charges

Describe the type and frequency of your pain

When

Notice: Not all patients require X-Rays to determine type of care and length of care. If your examination warrants x-ray analysis, the following office policy prevails:

11 + 3 =