Patient Health Assessment
General Information
Patient Name
Date
Provider Name
Primary Care Physician
Sex
M
F
Date Of Birth
Marital Status
S
M
W
D
Children
Soc Sec
Patient Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
eMail Address
Patient Employer
Patient Occupation
Subscriber Name
Relation To Patient
Subscriber Employer
Subscriber
Social Security #
Referred For Treatment By
Health Insurance Plan
Group#
Member#
Have You Ever Had Chiropractic Care?
Yes
No
Where And When
Complaint History
1.
Describe your current complaint and how the problem began.
How Long Have You Had This Condition?
2.
How Would You Describe The Pain?
Sharp
Soreness
Throbbing
Tingling
Dull
Stiffness
Spasm
Burning
Ache
Weakness
Numbness
Shooting
3.
How Would You Rate The Intensity Of Your Pain?
(No Pain)
Moderate Pain
Terrible/Unbearable Pain
4.
How Often Is The Pain Present?
Constant (81-100%)
Frequent (51-80%)
Occasional (26-50%)
Intermittent (25% or less)
5.
Since Your Problem Began, Is The Pain?
Getting Worse
Getting Better
Staying The Same