New Patient Forms For Your First Appointment New Patient Papers Terms of Acceptance Our Privacy Pledge Clinic and financial policy New Patient Form Reason for VisitPatient InformationHealth HistoryNew Patient Form Name * Name First First Last Last Today's Date * What is the reason for your visit today? Headache Neck Pain Mid-Back Pain Low Back Pain Other What caused this complaint(s)? Is it getting worse? Yes No Constant Comes and Goes Have you had this or similar complaint in the past? Yes No When did this complaint begin? When did you have this complaint in the past? What does your complaint(s) feel like? Check all that apply: Sharp Dull Sore Stiff Tight Aching Spasms Throbbing Stabbing Shooting Burning Cramping Nagging Tingling Numbness Other Describe where you are feeling pain today. On the scale below, please circle the severity of your main complaint right now: 1 2 3 4 5 6 7 8 9 10 No pain | Moderate pain | Worst possible pain What area(s) does the pain radiate, shoot, or travel to? (if applicable) What aggravates this complaint? Check all that apply: Sitting Standing Walking Getting up from seat Walking stairs Inactivity Sleeping Physical Activity Exercise Movement Bending forward Bending backward Twisting Reaching Lifting Desk work Sneezing Coughing Everything Unknown Other What relieves this complaint? Check all that apply: Sitting Standing Walking Resting Exercise Movement Stretching Massage Chiropractic Heat Ice Laying down Medication Nothing Unknown Other With time are your symptoms: Improving Worsening Not changing How often do you experience your symptoms? 25% of the day 50% of the day 75% of the day 100% of the day Time of Complaint MorningAs day progressesAfternoonEveningWhile sleepingDuring activitiesAfter activitiesSymptoms are constant and do not changeOther Have you seen other doctors for this complaint? Yes No Doctor's Name Date consulted Diagnosis Is this condition interfering with your: Check all that apply Sleep Getting in or out of bed or chair Personal care Travel Work Recreation Lifting Walking Standing Daily routine Social Activities Exercise Other Is your complaint interfering with your daily activities? Not at all A little bit Moderately Quite a bit Extremely If you are human, leave this field blank. Next Δ Call today! (801) 446-6220 Schedule your appointment today!
