Powers Chiropractic

                                                            CHIRO - PATIENT INTAKE FORM

                     Patient: ____________________        Date:_________           Onset:________
                     
1.	What brings you into our office today? ( List Complaints)
2.	Problem a. __________________________________________          Severity (on scale of 0 to 10)______
3.	Problem b. __________________________________________          Severity (on scale of 0 to 10)______
4.	Problem c.___________________________________________         Severity (on scale of 0 to 10)______

5.	What makes problem (a) worse.______________________________________________
6.	What makes problem (b) worse. ______________________________________________ 
7.	What makes problem (c) worse ______________________________________________

                             8.   What makes problem (a) better ______________________________________________
                             9.   What makes problem (b) better_______________________________________________
                           10.  What makes problem (c) better _______________________________________________

11.Is today's problem caused by: ___ Injury     __ Auto Accident      __ Workman's Compensation   __ Unknown    

                             12. How often do you experience your symptoms? 
                                 Problem   A  ___ Constantly ___ Frequently ___ Intermittently ___ Occasionally	             
          Problem    B ___ Constantly ___ Frequently ___ Intermittently ___ Ocassionally
                         Problem    C ___ Constantly ___ Frequently ___ Intermittently ___ Ocassionally  
                                
                              13. How would you describe the type of pain?

                            
    __Sharp                                        __ Numb
    __Dull                                           __ Tingly 
    __Sharp with motion                    __  Stiff
    __Diffuse                                       __ Stabbing with motion 
   __Achy                                           __ Other:_________
  __Burning__
  __Shooting

14.    How are your symptoms changing with time?
    __Getting Worse        __Staying the Same        __Getting Better
15. How much has the problem interfered with your work?
    __ Not at all	__ A little bit          __ Moderately       __ Quite a bit        __ Extremely
16. How much has the problem interfered with your social activities?
     __ Not at all	__ A little bit          __ Moderately       __Quite a bit           __ Extremely
17. Who else have you seen for your problem?
    __ Chiropractor         __ Neuroligist          __ Primary Care Physician
    __ ER Physician       __ Orthopedist         __ Massage Therapist
    __ Physical Therapist    __  Other             __ No One
18. How long have you had this problem? _____________
19. How do you think your problem began?___________________________________________
20. Do you consider this problem to be severe?
    __   Yes	__ Yes, at times                  __ No