Initial Visit Intake Forms

(Just Print, Fill Out & Bring to your First Appointment)

   Jex Chiropractic Health Center

    

Name:____________________________________________________________Date:________________

Home Phone:_____________________________

Cell Phone:_______________________________

Address:______________________________________________________________________________

City:_____________________________________State:_______Zip:________________

E-Mail:___________________________________     Sex  F        Birthdate:____________________

SSN:________________________________  Marital Status:   M   D   S   W

How did you hear of us?__________________________________________________________________

 

Employer:

Company Name:_____________________________________Occupation:__________________________

Address:______________________________________________________________________________

City:_____________________________________State:________Zip:_______________

Work Phone:______________________________

 

Please provide copy of insurance card or fill out the following information:

Insurance Name:_______________________________________________________________________

Insurance ID#___________________________________Group#________________________________

Insurance Phone:__________________________________

Relationship to insured:            Self                    Spouse            □Child

 

Secondary Insurance Information

Insurance Name:_______________________________________________________________________

Insurance ID#___________________________________Group#________________________________

Insurance Phone:_________________________________

 

Main purpose of Appointment:____________________________________________________________

____________________________________________________________________________________

On the job injury     Auto Accident      Home Injury

Date of Accident:_________________________________

 

If pain brought you in today are you aware of what caused it?___________________________________

____________________________________________________________________________________

What is the level of discomfort you are feeling?

   □ Minimal        Mild        Moderate       Severe      □ Very Severe

 

How long has this problem persisted?_________What activities aggravate your condition?___________________________________________________________________________________

Names of other physicians seen for this condition:____________________________________________

What information did they give you regarding this condition:____________________________________

___________________________________________________________________________________

What did they recommend?______________________________________________________________

Results of recommendations?____________________________________________________________

Family Physician Name:____________________________________

 

Date of Last:

Physical Exam_____________________Spinal Exam________________________

Spinal X-ray_______________________MRI______________________________

CT-Scan__________________________Other_____________________________

Name of Facility taken at:______________________________________________

City:_________________________________State:_________________________

 

Prescription Medications:

____________________          ______________________          ______________________

____________________          ______________________          ______________________

____________________          ______________________          ______________________

 

Vitamins/Herbs/Supplements Currently Taking:

____________________          ______________________          ______________________

____________________          ______________________          ______________________

 

LIST ALL PAST INJURIES AND SURGERIES (Description & Date)

 

Falls:_____________________________________________________________________________________

_________________________________________________________________________________________

 

Head Injuries:_____________________________________________________________________________

________________________________________________________________________________________

 

Broken Bones:____________________________________________________________________________

________________________________________________________________________________________

 

Dislocations:_______________________________________________________________________________

_________________________________________________________________________________________

 

Spinal Injuries:_____________________________________________________________________________

_________________________________________________________________________________________

 

Surgeries:_________________________________________________________________________________

__________________________________________________________________________________________

 

 Any History of the following:

High Blood Pressure                High Cholesterol

Dizziness                                  Nausea

Blurred Vision                          □ Diabetes    If yes, do you take insulin?______

 

Have you ever seen a Chiropractor before?    Yes     No

When?__________________________________________________________________________

Name of Chiropractor seen:__________________________________________________________

 

Are you pregnant?    □ Yes          □ No

 

Do you regularly take aspirin or blood thinners?    Yes          No

 

Do you sleep on your:       Back      Side        Stomach

 

 Place a √ to indicate if you have or had any of the following:

 

AIDS/HIV                             □ Gout                                                □ Pain in Shoulders

 

□ Allergies                                □ Heart Disease                                   □ Pain in Arms

 

□ Anemia                                  □ High Blood Pressure                        □ Pain in Joints

 

□ Anxiety                                  □ Headaches                                       □ Pinched Nerves

 

□ Arthritis                                 □ Herniated Disc                                □ Pins & Needles in Legs

 

□ Asthma                                  □ Hypertension                                  □ Pins & Needles in Arms

 

□ Bleeding Disorders                 □ Indigestion                                    □ Pins & Needles in Hands

 

□ Blurred Vision                        □ Intestinal Gas                                 □ Ringing in Ears

 

□ Cancer                                    □ Insomnia                                       □ Sinus Trouble

 

□ Cold Hands                             □ Irritable Bowl                                □ Swollen Ankles

 

□ Cold Feet                                □ Irritability                                      □ Swollen Joints

 

□ Cold Sweats                           □ Low Back Pain                               □ Stomach Trouble

 

□ Chest Pains                            □ Low Blood Pressure                       □ Shortness of Breath

 

□ Constipation                          □  Loss of Memory                             □ Stress

 

□ Diarrhea                                 □ Loss of Balance                             □ Stroke

 

□ Diabetes                                 □ Loss of Smell                                 □ Sleeping Problems

 

□ Depression                            □ Menstrual Problems                        □ Thyroid Disease

 

□ Dizziness                               □ Mid Back Pain                                 □ Tightness in Shoulder

 

□ Fainting                                □ Migraines                                        □ Twitching of Face

 

□ Fatigue                                 □ Muscle Spasms                                □ Ulcers

 

□ Food Allergy                         □ Neck Pain                                       □ Wounds

 

□ Gall Bladder Disease             □ Numbness                                     □ Other______________

 

□ Grating in Neck                    □ Pain in Legs & Feet