1. The symptom(s) that have prompted me to seek care today include:
2. And are the result of (darken circle):
Work
An accident or injury
Auto Other
A worsening long-term problem
Wellness Other
3. Onset (When did you first notice your current symptoms?)
6. Quality of symptoms (What does it feel like?)
Numbness
Tingling
Stiffness
Dull
Aching
Cramps
Nagging
Sharp
Burning
Shooting
Throbbing
Stabbing
Other
7. Location (Where does it hurt?)Circle the area(s) on the illustration.
4. Intensity (How extreme are yourcurrent symptoms?)
0 10
Absent Uncomfortable Agonizing
5. Duration and Timing (When did it start and how often do you feel it?)
Constant Comes and goes. How Often?
8. Radiation (Does it affect other areas of your body? To what areas does the pain radiate, shoot or travel.)
9. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)
What tends to worsenthe problem?
What tends to lessenthe problem?
10. Prior interventions (What have you done to relieve the symptoms?)
Prescription medication
Over-the-counter drugs
Homeopathic remedies
Physical therapy
Surgery
Acupuncture
Chiropractic
Massage
11. What else should Dr. Leonette know about your current condition?
12. How does your current condition interfere with your:
13. Review of SystemsChiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please darken the circle beside any condition that you’ve Had or currently Have and initial to the right.
Consu
ltati
on N
ote
s
2/4PAGE
Ice
Heat
Other
“0” for current condition“X” for conditions experienced in the past
Work or career:
Recreational activities:
Personal relationships:
Household responsibilities:
a. Musculoskeletal
Osteoporosis
Knee injuries
Arthritis
Foot/ankle pain
Scoliosis
Shoulder problems
Neck pain
Elbow/wrist pain
Back problems
TMJ issues
Hip disorders
Poor posture Initials
b. Neurological
Anxiety Depression Headache Dizziness Pins and Numbness
c. Cardiovascular
High blood Low blood High cholesterol Poor circulation Angina Excessive
d. Respiratory
Asthma Apnea Emphysema Hay fever Shortness Pneumonia
g. Integumentary
Skin cancer Psoriasis Eczema Acne Hair loss Rash
f. Sensory
Blurred vision Ringing in ears Hearing loss Chronic ear Loss of smell Loss of taste
Past Personal, Family and Social HistoryPlease identify your past health history, including accidents, injuries, illnesses and treatments. Please complete each section fully.
14. IllnessesCheck the illnesses you have Had in the past or Have now.
AIDS
Alcoholism
Allergies
Arteriosclerosis
Cancer
Chicken pox
Diabetes
Epilepsy
Glaucoma
Goiter
Gout
Heart disease
Hepatitis
HIV Positive
Malaria
Measles
Multiple Sclerosis
Mumps
Polio
Rheumatic fever
Scarlet fever
Sexually transmitted disease
Stroke
15. OperationsSurgical interventions, which may or may not have included hospitalization.
Appendix removal
Bypass surgery
Cancer
Cosmetic surgery
Elective surgery:
Eye surgery
Hysterectomy
Pacemaker
Spine
Tonsillectomy
Vasectomy
Other:
17. InjuriesHave you ever...
Had a fractured or broken bone
Had a spine or nerve disorder
Been knocked unconscious
Been injured in an accident
16. TreatmentsCheck the ones you’ve received in the Past or are receiving Currently.
21. Activities of Daily LivingHow does this condition currently interfere with your life and ability to function?
Sitting
Rising out of chair
Standing
Walking
Lying down
Bending over
Climbing stairs
Using a computer
Getting in/out of car
Driving a car
Looking over shoulder
Caring for family
No Effect
Mild Effect
Moderate Effect
Severe Effect
4/4PAGE
Grocery shopping
Household chores
Lifting objects
Reaching overhead
Showering or bathing
Dressing myself
Love life
Getting to sleep
Staying asleep
Concentrating
Exercising
Yard work
22. What is the major stressor in your life?
24. What is the type and approximate age of your mattress and pillow? 25. What is your preferred sleeping position?
23. How much sleep do you average per night?
26. Describe your typical eating habits:
Hours
Skip breakfast Two meals a day Three meals a day
28. In addition to the main reason for your visit today, what additional health goals do you have?
27. What would be the most significant thing that you could do to improve your health?
I instruct the chiropractor to deliver the care that, in his or her professional judgement, can best help me in the
restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best
available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct
healing art from medicine and does not proclaim to cure any named disease or entity.
I may request a copy of the Privacy Policy and understand it describes how my personal health information is
protected and released on my behalf for seeking reimbursement from any involved third parties.
I realize that an X-ray examination may be hazardous to an unborn child and I certify that to
the best of my knowledge I am not pregnant. Date of last menstrual period (MM/DD/YYYY):
I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters,
emails or health information to me as an extension of my care in this office.
I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible
for the payment of any covered or non-covered services I receive.
To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the
presence, severity or cause of my health concern.
AcknowledgementsTo set clear expectations, improve communications and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.
If the patient is a minor child, print child’s full name:
Date _______________________________________________PATIENT INFORMATION
Name ____________________________________________ Birthdate _________________________ Soc. Sec. # ___________________________________Address _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Telephone ________________________________________________________ Occupation ______________________________________________________
EMPLOYEREmployer Name _____________________________________________________________________________________________________________________Employer Address ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Employer Telephone ______________________________________________ Injury Verified By (For Office Use Only) ____________________________Contact Person _____________________________________________________________________________________________________________________
WORKER COMPENSATION CARRIER (FOR OFFICE USE ONLY)Worker Compensation Carrier _______________________________________________________________________________________________________Carrier Address __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Carrier Phone Number ____________________________________________ Coverage Verified by _____________________________________________
INJURY INFORMATION a.m.Date of Injury ____________________________________________________ Time _______________________________________ p.m.Place of Injury _______________________________________________________________________________________________________________________Accident reported to employer? Yes No Name of person you reported accident to ________________________________________________Give full description of how accident happened ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you lost time from work? Yes No How much? ______________________________________________________________________________Other doctors seen for this condition:Doctor’s Name ______________________________________________________ Diagnosis _____________________________________________________Were X-Rays taken? Yes No Other Tests? Yes NoIf yes, by whom? Please list test(s) and result(s) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Any previous Worker Compensation Injuries? Yes No Date(s) of previous Injuries _________________________________________________Describe previous Worker Compensation Injuries _____________________________________________________________________________________
AUTHORIZATIONI clearly understand and agree that all services rendered to me are charged directly to me and that I will promptly pay all charges in the event that my Worker Compensation benefits is denied.
Patient’s Signature _________________________________________________________________ Date __________________________________
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Ð Ñ Ò Ó Ô Õ Ñ Ö × Ó Ø Ù Ú Ø Û Ü Ý Ó Ü Þ ß à à Öá â ã ä å æ Û Ó Ñ ç Ý Ø Õ Õ Ý Þ ç è Ó Ý Õ ãé Ø Ó ê ë Õ Ú Ù Ø Ý Þ ä ì í î ã ã âï ã â ð ñ ò ã ã ó ò ã â ô á â õ í â á íö Þ ÷ ø ù ú û ü û ý û þ ú û ÿ ù ý � � � � � � ø þ � � � � þ ý û � � � � � þ ý û � �ß Ø Ó Ô Û Ü � ß Ø Û Ü Ý Ó Ü Õ å ö è Ñ ê Õ Ø Ý Û Ñ ê Ý × Û Ý ö × Û Ô Õ Ü Õ Ø Ý Û Ó Ñ Ø Ó ë × Ý Ý Ù Ú Ø Ó Ô Û Ü � Ø Õ ë Û Ø ê Ó Ñ ë � Ú Ø Ù Ý Õ Ü Ý Õ ê × Õ Û Ò Ý ×Ó Ñ � Ù Ø Û Ý Ó Ù Ñ å ö è Ñ ê Õ Ø Ý Û Ñ ê Ý × Û Ý Ý × Ó Ó Ñ � Ù Ø Û Ý Ó Ù Ñ Ü Û Ñ Û Ñ ê � Ó Ò Ò Õ è Õ ê Ý Ù �Ö Ù Ñ ê è Ü Ý Þ Ú Ò Û Ñ Û Ñ ê ê Ó Ø Õ Ü Ý � Ý Ø Õ Û Ý Õ Ñ Ý Û Ñ ê � Ù Ò Ò Ù � ó è Ú Û Ù Ñ ë Ý × Õ × Õ Û Ò Ý × Ü Û Ø Õ Ú Ø Ù Ô Ó ê Õ Ø � × Ù Û � Õê Ó Ø Õ Ü Ý Ò � Û Ñ ê Ó Ñ ê Ó Ø Õ Ü Ý Ò � Ó Ñ Ô Ù Ò Ô Õ ê Ó Ñ Ú Ø Ù Ô Ó ê Ó Ñ ë � Ý Ø Õ Û Ý Õ Ñ Ý å� Ý Û Ó Ñ Ú Û � Õ Ñ Ý � Ø Ù Ý × Ó Ø ê ó Ú Û Ø Ý � Ú Û � Õ Ø åÖ Ù Ñ ê è Ü Ý Ñ Ù Ø Û Ò × Õ Û Ò Ý × Ü Û Ø Õ Ù Ú Õ Ø Û Ý Ó Ù Ñ è Ü × Û � è Û Ò Ó Ý � Û Õ Õ Ñ Ý Û Ñ ê Û Ü Ü Ø Õ ê Ó Ý Û Ý Ó Ù Ñ å� � � � � � �� � � � � � � � �� � � � � � � � ! " # $ % # � & ' () * + , , * - . , * / , 0 0 1 , + 2 3 4 5 2 , , * 3 6 7 8 3 0 4 9 * / : - * 3 , 0 ; 5 * 7 * 2 . , 0 ; 0 < 5 = 0 , 2 7 * 0 ; > 5 2 ? + 7 @ > 5 + 7 , 2 7 * A B 1 < ,6 7 8 3 0 4 9 * / : - * 3 , 7 0 < 9 / 3 0 , 1 * 0 1 , + 2 3 * / 1 * 7 + < A * C
o D 3 / 2 ? 2 / < + 9 5 * ; < A * / , 0 A 2 : 3o E 0 - - < 3 2 7 + , 2 0 3 A 1 + 5 5 2 * 5 A . 5 0 F 2 1 2 , * / 0 1 , + 2 3 2 3 : , F * 6 7 8 3 0 4 9 * / : - * 3 ,o
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Patient-Specific Functional Scale Please list activities you cannot do, have difficulty doing and/or are affected by your condition.
Sample activities are, but not limited to:
Sitting, Rising out of Chair, Standing, Walking, Lying Down, Bending Over, Climbing Stairs, Using a
Computer, Getting in/out of car, Driving a car, Looking Over Shoulder, Caring for family, Grocery
