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? YesNo 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