WINSTON-SALEM-Salama-Chiropractic-New-Patient-HISTORY-INTAKE-Form-2-27-2019

New Patient History Intake Form

Salama Chiropractic Center

APPOINTMENT INFORMATION

Which Salama Chiropractic Office Is Your Appointment Scheduled At?

Greensboro - 3410 West Wendover Aveue, Suite A Greensboro - 2608-A Lawndale Drive Oak Ridge - 1692 NC Highway 68, Suite E Winston-Salem - 1515 Hanes Mall Boulevard Charlotte - 2200 Randolph Road

PATIENT INFORMATION

Patient Full Name (First, Middle & Last Names)

Date of Birth

Your Email Address

Date

SYMPTOMS / AREAS OF COMPLAINT

Please List/Describe Your Symptoms Below in Order of Severity

* FILL OUT FORM FIELDS FOR EACH SYMPTOM INDIVIDUALLY*

* DO NOT GROUP SYMPTOMS *

SYMPTOM 1

1-A. What is your symptom?

1-B. How long have you had this symptom?

1-C. What is the pain level - Using a scale from 0-10 (10 being the worst)?

1-D. How often do you experience this symptom?

Constantly (76-100% of the time) Frequently (51-75% of the time) Occasionally (26-50% of the time) Intermittently (1-25% of the time)

1-E. How would you describe the type of pain?

Other

1-F. How is this symptom changing with time?

Getting worse Not changing Getting better

SYMPTOM 2 (If applicable. If not, skip to question 6)

2-A. What is your symptom?

2-B. How long have you had this symptom?

2-C. What is the pain level - Using a scale from 0-10 (10 being the worst)?

2-D. How often do you experience this symptom?

Never Constantly (76-100% of the time) Frequently (51-75% of the time) Occasionally (26-50% of the time) Intermittently (1-25% of the time)

2-E. How would you describe the type of pain?

Other

2-F. How is this symptom changing with time?

No Change Getting worse Not changing Getting better

SYMPTOM 3 (If applicable. If not, skip to question 6)

3-A. What is your symptom?

3-B. How long have you had this symptom?

3-C. What is the pain level - Using a scale from 0-10 (10 being the worst)?

3-D. How often do you experience this symptom?

Never Constantly (76-100% of the time) Frequently (51-75% of the time) Occasionally (26-50% of the time) Intermittently (1-25% of the time)

3-E. How would you describe the type of pain?

Other

3-F. How is this symptom changing with time?

No Change Getting worse Not changing Getting better

SYMPTOM 4 (If applicable. If not, skip to question 6)

4-A. What is your symptom?

4-B. How long have you had this symptom?

4-C. What is the pain level - Using a scale from 0-10 (10 being the worst)?

4-D. How often do you experience this symptom?

Never Constantly (76-100% of the time) Frequently (51-75% of the time) Occasionally (26-50% of the time) Intermittently (1-25% of the time)

4-E. How would you describe the type of pain?

Other

4-F. How is this symptom changing with time?

No Change Getting worse Not changing Getting better

SYMPTOM 5 (If applicable. If not, skip to question 6)

5-A. What is your symptom?

5-B. How long have you had this symptom?

5-C. What is the pain level - Using a scale from 0-10 (10 being the worst)?

5-D. How often do you experience this symptom?

Never Constantly (76-100% of the time) Frequently (51-75% of the time) Occasionally (26-50% of the time) Intermittently (1-25% of the time)

5-E. How would you describe the type of pain?

Other

5-F. How is this symptom changing with time?

No Change Getting worse Not changing Getting better

If applicable - List any other symptoms you would like the doctor to evaluate excluding the ones previously listed.

6. How much has the problem interfered with your work?

7. How much has the problem interfered with your social activities?

8. How long have you had this problem?

9. How do you think your problem began?

10. Do you consider this problem to be severe?

Yes Yes, at times No

11. What aggravates your problem?

12. What makes your problem better?

13. What concerns you the most about your problem; what does it prevent you from doing?

14a. What is your height?

14b. What is your weight?

14c. What is your date of birth?

14d. What is your occupation?

15. How would you rate your overall health?

16. What type of exercise do you do?

Strenuous Moderate Light None

17. Indicate if you have any Immediate family members with any of the following:

18. Who else have you seen for your problem?

Other

19a. What treatment have you already received for your condition?

Other

19b. Name and address of other doctor{s) who have treated you for your condition.

19c. What treatment was given and by whom?

19d. What were the results of your treatment?

Date of Last Physical Exam

Date of Last Spinal Exam

Date of Last Dental X-Ray

Date of Last Spinal X-Ray

Date of Last Chest X-Ray

Date of Last MRI, CT-Scan, Bone Scan

Date of Last Blood Test

Date of Last Urine Test

Check "Yes" or "No" to indicate if you have had any of the following:

AIDS/HIV

Yes No

Alcoholism

Yes No

Allergy Shots

Yes No

Anemia

Yes No

Anorexia

Yes No

Appendicitis

Yes No

Arthritis

Yes No

Asthma

Yes No

Bleeding Disorders

Yes No

Breast Lump

Yes No

Bronchitis

Yes No

Bulimia

Yes No

Cancer

Yes No

Cataracts

Yes No

Chemical Dependency

Yes No

Chicken Pox

Yes No

COVID-19

Yes No

Diabetes

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Fractures

Yes No

Glaucoma

Yes No

Goiter

Yes No

Gonorrhea

Yes No

Gout

Yes No

Heart Disease

Yes No

Hepatitis

Yes No

Hernia

Yes No

Herniated Disk

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Measles

Yes No

Migraine Headaches

Yes No

Miscarriage

Yes No

Mononucleosis

Yes No

Multiple Sclerosis

Yes No

Mumps

Yes No

Osteoporosis

Yes No

Pacemaker

Yes No

Parkinson's Disease

Yes No

Pinched Nerve

Yes No

Pneumonia

Yes No

Polio

Yes No

Prosthesis

Yes No

Psychiatric Care

Yes No

Rheumatoid Arthritis

Yes No

Rheumatic Fever

Yes No

Scarlet Fever

Yes No

Sexually Transmitted Disease

Yes No

Stroke

Yes No

Suicide Attempt

Yes No

Thyroid Problems

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors, Growths

Yes No

Typhoid Fever

Yes No

Ulcers

Yes No

Vaginal Infections

Yes No

Whooping Cough

Yes No

Other

COVID-19 Vaccination Status

Select your COVID-19 vaccination status

No vaccine received. Yes, 1 dose of 1 - less than 2 weeks (Johnson & Johnson Janssen) Yes, 1 dose of 1 - greater than 2 weeks (Johnson & Johnson Janssen) Yes, 1 of 2 doses (Pfizer-BioNTech or Moderna) Yes, 2 of 2 doses (Pfizer-BioNTech or Moderna) - less than 2 weeks. Yes, 2 of 2 doses (Pfizer-BioNTech or Moderna) - greater than 2 weeks.

20. What habits do you currently do?

Smoking

Yes No

Packs Per Day

Coffee/Caffeine Drinks

Yes No

Cups Per Day

Alcohol

Yes No

Drinks Per Week

High Stress Level

Yes No

Reason For High Stress Level

21. Are you pregnant?

Yes No

Due Date

22. List all prescription medications/supplements you are currently taking:

23. List all of the over-the-counter medications you are currently taking:

24. List all surgical procedures you have had:

25. What activities do you do at work?

Sit

Most of the day Half of the day A little of the day

Stand

Most of the day Half of the day A little of the day

Computer Work

Most of the day Half of the day A little of the day

On The Phone

Most of the day Half of the day A little of the day

26. What activities do you do outside of work?

27. Have you ever been hospitalized?

Yes No

If yes, why?

28. Have you ever seen a chiropractor?

Yes No

If yes, what was your experience?

29. Have you had significant past trauma?

Yes No

30. Anything else pertinent to your visit today?

Print Patient Name

New Patient History Intake Form

Salama Chiropractic Center

APPOINTMENT INFORMATION

PATIENT INFORMATION

SYMPTOMS / AREAS OF COMPLAINT

Please List/Describe Your Symptoms Below in Order of Severity

*** FILL OUT FORM FIELDS FOR EACH SYMPTOM INDIVIDUALLY***

*** DO NOT GROUP SYMPTOMS ***

SYMPTOM 1

SYMPTOM 2 (If applicable. If not, skip to question 6)

SYMPTOM 3 (If applicable. If not, skip to question 6)

SYMPTOM 4 (If applicable. If not, skip to question 6)

SYMPTOM 5 (If applicable. If not, skip to question 6)

Check "Yes" or "No" to indicate if you have had any of the following:

COVID-19 Vaccination Status

20. What habits do you currently do?

25. What activities do you do at work?

* FILL OUT FORM FIELDS FOR EACH SYMPTOM INDIVIDUALLY*

* DO NOT GROUP SYMPTOMS *