New Patient Intake Form

First Name*

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Middle Name

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Last Name*

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Date

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Gender

Male Female Other

If Other

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Date of Birth

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Social Security Number

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Address

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Home Phone

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Cell Phone *

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Email *

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I authorize Bourree Chiropractic and Massage to leave health related or appointment related voicemails at the number or numbers checked:

Home Cell

Preferred Language

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Ethnicity

Hispanic Non-Hispanic Unknown (A person who cannot or does not want to declare ethnicity).

Race

If Other

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Employer

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Occupation

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Emergency Contact

Name*

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Cell

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Home

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Email

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Primary Health Care Provider

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Phone Number

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Health History

Have you received Chiropractic, Massage Therapy, or Therapeutic Cold Laser treatment before?

Yes No

What medications are you currently taking? Please include supplements, herbal remedies, and over the counter medications.

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Please list other medications you have taken over the last 3 months:

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List all allergies (including food and environmental):

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Do you smoke?

Cigarettes

Yes No

E-Cigs

Yes No

Marijuana

Yes No

Chewing Tobacco

Yes No

Would you like smoking cession materials?

Yes No

How many alcoholic beverages do you consume?

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Please list and explain. Include dates and treatment received if possible:

Surgeries:

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Accidents:

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Major Illness:

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Date of last physical exam:

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Date of last blood test:

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Date of last X-Rays:

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Family Medical History

Father: Alive?

Yes No

Current Age:

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Age of Death if passed:

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Cause of Death:

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Father’s general health is:

Excellent Good Fair Poor

Check those to which the answer is yes (leave others blank)

Mother: Alive?

Yes No

Current Age:

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Age of Death if passed:

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Cause of Death:

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Mother’s general health is:

Excellent Good Fair Poor

Check those to which the answer is yes (leave other blank)

Siblings

Number of brothers:

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Number of sisters:

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Age Range:

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Health Problems:

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Additional Family Health problems:

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Please check All Current and Previous Conditions:

General:

Headaches

Current Past

Fatigue

Current Past

Sinus

Current Past

Sleep Disturbances

Current Past

Pain

Current Past

Infections

Current Past

Fever

Current Past

Skin Conditions:

Rashes

Current Past

Athletes foot

Current Past

Warts

Current Past

Endocrine System:

Thyroid dysfunction

Current Past

Diabetes

Current Past

Respiratory and Cardiovascular:

Heart Disease

Current Past

Poor Circulation

Current Past

Shortness of breath

Current Past

High/ Low blood pressure

Current Past

Asthma

Current Past

Irregular heart beat

Current Past

Lymphedema

Current Past

Chest pain

Current Past

Blood clots

Current Past

Swollen ankles

Current Past

Stroke

Current Past

Varicose veins

Current Past

Reproductive System:

Pregnancy

Current Past

Painful/ emotional menses

Current Past

Fibrotic cysts

Current Past

Muscles and Joints:

Rheumatoid Arthritis

Current Past

Broken bones

Current Past

Lupus

Current Past

Strains/sprains

Current Past

Weak/ sore muscles

Current Past

Scoliosis

Current Past

Spams/ cramps

Current Past

Neck/ shoulder pain

Current Past

Arm pain

Current Past

Low back pain

Current Past

Hip pain

Current Past

Leg pain

Current Past

Osteoarthritis

Current Past

Spinal problems

Current Past

Disc problems

Current Past

TMJ/ jaw pain

Current Past

Tendonitis/ bursitis

Current Past

Stiff/ painful joints

Current Past

Digestive/ Elimination System:

Bowel dysfunction

Current Past

Bladder dysfunction

Current Past

Gas/ bloating

Current Past

Kidney dysfunction

Current Past

Abdominal pain

Current Past

Nervous System:

Head injury/ concussion

Current Past

Depression/ anxiety

Current Past

Sciatica/ shooting pain

Current Past

Chronic pain

Current Past

Numbness/ tingling

Current Past

Dizziness/ ear ringing

Current Past

Loss of memory/ confusion

Current Past

Cancer or Tumor:

Benign

Current Past

Malignant

Current Past

Contract for Care:

I promise to participate fully as a member of my health care team. I will make sound choices regarding my treatment plan based on the information provided by my manual therapist and other members of my health care team, and my experiences of those suggestions. I agree to participate in the self-care program we select. I promise to inform my practitioner any time I feel my well being is threatened or compromised.

I expect my manual therapist or other health care professional to provide safe and effective treatment. Consent for Care It is my choice to receive care, and I give my consent to receive treatment. I have reported all health conditions that I am aware of and will inform my practitioner of any changes in my health.

First Name

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Last Name

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Signature*

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Date *

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Patient Evaluation Chart and Questionnaire

Name

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Date

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Primary Onset (select one):

Please indicate where your major symptoms are located then put the appropriate letters from the chart listed below.

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CP – Constant pain
P – Pain
S – Swelling
T – Tenderness
N – Numbness
Tg – Tingling
R – Redness
E – Effusion (puffiness or edema)
L - Limitation
W - Weakness

How long have you had these symptoms? (Itemize the different body areas if appropriate):

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Symptom List

Please list the concerns that brought you in today:

First Area of complaint:

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Pain level:

Mild Moderate Severe

Frequency:

Constant Intermittent

Symptoms:

Aches Stabs Burns Others

If Others

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Rate your symptom level on a 0-10 scale. (0- no pain 5 moderate pain 10 worst pain possible):

Second Area of complaint:

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Pain level:

Mild Moderate Severe

Frequency:

Constant Intermittent

Rate your symptom level on a 0-10 scale. (0- no pain 5 moderate pain 10 worst pain possible):

Symptoms:

Aches Stabs Burns Others

If Others

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Third Area of complaint:

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Pain level:

Mild Moderate Severe

Frequency:

Constant Intermittent

Symptoms:

Aches Stabs Burns Others

If Others

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Rate your symptom level on a 0-10 scale. (0- no pain 5 moderate pain 10 worst pain possible):

Fourth Area of complaint:

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Pain level:

Mild Moderate Severe

Frequency:

Constant Intermittent

Symptoms:

Aches Stabs Burns Others

if Others

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Rate your symptom level on a 0-10 scale. (0- no pain 5 moderate pain 10 worst pain possible):

Fifth Area of complaint:

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Pain level:

Mild Moderate Severe

Frequency:

Constant Intermittent

Symptoms:

Aches Stabs Burns Others

Rate your symptom level on a 0-10 scale. (0- no pain 5 moderate pain 10 worst pain possible:

Activities of Daily Living Questionnaire

Work:

What type of work do you do?

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How many hours per day are you able to work now?

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Prior to Injury?

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Days per week now?

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How is your work affected or lost by your injury?

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Home/Family:

List the activities affected by your injury?

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Sleep:

How many hours per night do you sleep now?

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Prior to injury?

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Do you feel rested now?

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Prior to injury?

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What affects your sleep? (Examples- pain, not able to go to sleep, not able to wake up etc.)

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Social/Recreational:

Activities:

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Prior to injury?

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How are your current activities affected?

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Name:

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Date:

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Signature:*

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Oswestry Neck Pain Disability Questionnaire

PLEASE READ: This questionnaire is designed to enable use to understand how much you NECK pain has affected your ability to manage your everyday activities. Please answer each section by selecting the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST SELECT THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.

Section 1 – Pain Intensity

A – The pain comes and goes and is very mild. B – The pain is mild and does not vary much. C – The pain comes and goes and is moderate. D – The pain is moderate and does not vary much. E – The pain comes and goes and is severe. F – The pain is severe and does not vary much

Section 2 – Personal Care

A – I would not have to change my way of washing or dressing in order to avoid pain B – I do not normally change my way of washing or dressing even though it causes some pain. C – Washing and dressing increases the pain, but I manage not to change my way of doing it. D – Washing and dressing increases the pain and I find it necessary to change my way of doing it. E – Because of the pain, I am unable to do some washing and dressing without help. F – Because of the pain, I am unable to do any washing or dressing without help.

Section 3 – Lifting

A – I can lift heavy weights without extra pain. B – I can lift heavy weights, but it causes extra pain. C – Pain prevents me from lifting heavy weights off the floor. D – Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently position, (example on a chair or table). E – Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently position. F – I can only lift very light weights, at the most.

Section 4 –Walking

A - Pain does not prevent me from walking any distance. B - Pain prevents me from walking more than one mile. C - Pain Prevents me from walking more than 1/2 mile. D - Pain prevents me from walking more than 1/4 mile. E - I can only walk while using a cane or on crutches. F - I am in bed most of the time and have to crawl to the toilet.

Section 5 – Sitting

A - I can sit in any chair as long as I like without pain. B - I can only sit in my favorite chair as long as I like. C - Pain prevents me from sitting more than one hour. D - Pain prevents me from sitting more than 1/2 hour. E - Pain prevents me from sitting more than 10 minutes. F - Pain prevents me from sitting at all.

Section 6 – Standing

A - I can stand as long as I want without pain. B - I have some pain while standing, but it does not increase with time. C - I cannot stand for longer than one hour without increasing pain. D - I cannot stand for longer than 1/2 hour without increasing pain. E - I cannot stand for longer than 10 minutes without increasing pain. F - I avoid standing, because it increases the pain straight away.

Section 7 – Sleeping

A - I get no pain in bed. B - I get pain in bed, but it does not prevent me from sleeping well. C - Because of pain, my normal night's sleep is reduced by less than one-quarter. D - Because of pain, my normal night's sleep is reduced by less than one-half. E - Because of pain, my normal night's sleep is reduced by less than three-quarters. F - Pain prevents me from sleeping at all.

Section 8 – Social Life

A - My social life is normal and gives me no pain. B - My social life is normal, but increases the degree of my pain. C - Pain has no significant effect on my social life apart from limiting my more energetic activities. (example: dancing, ect.) D - Pain has restricted my social life and I do not go out very often. E - Pain has restricted my social life to my home. F - I have hardly any social life because of the pain.

Section 9 – Traveling

A - I get no pain while traveling. B - I get some pain while traveling, but none of my usual forms of travel make it any worse. C - I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. D - I get extra pain while traveling which compels me to seek alternative forms of travel. E - Pain restricts all forms of travel. F - Pain prevents all forms of travel except that done lying down.

Section 10 – Changing Degree of Pain

A - My pain is rapidly getting better. B - My pain fluctuates, but overall is definitely getting better. C - My pain seems to be getting better, but improvement is slow at present. D - My pain is neither getting better nor worse. E - My pain is gradually worsening. F - My pain is rapidly worsening.

Additional Comments:

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Name:

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Date:

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Score

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Oswestry Low Back Pain Disability Questionnaire

PLEASE READ: This questionnaire is designed to enable use to understand how much you LOWER BACK pain has affected your ability to manage your everyday activities. Please answer each section by selecting the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST SELECT THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.

Section 1 – Pain Intensity

A - The pain comes and goes and is very mild. B - The pain is mild and does not vary much. C - The pain comes and goes and is moderate. D - The pain is moderate and does not vary much. E - The pain comes and goes and is severe. F - The pain is severe and does not vary much.

Section 2 – Personal Care

A - I would not have to change my way of washing or dressing in order to avoid pain. B - I do not normally change my way of washing of dressing even though it causes some pain. C - Washing and dressing increases the pain, but I manage not to change my way of doing it. D - Washing and dressing increases the pain and I find it necessary to change my way of doing it. E - Because of the pain, I am unable to do some washing and dressing without help. F - Because of the pain, I am unable to do any washing or dressing without help.

Section 3 – Lifting

A - I can lift heavy weights without extra pain. B - I can lift heavy weights, but it causes extra pain. C - Pain prevents me from lifting heavy weights off the floor. D - Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently position (example- on a chair or table). E - Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently position. F - I can only lift very light weights at the most.

Section 4 –Walking

A - Pain does not prevent me from walking any distance. B - Pain prevents me from walking more than one mile. C - Pain prevents me from walking more than 1/2 mile. D - Pain prevents me from walking more than 1/4 mile. E - I can only walk while using a cane or on crutches. F - I am in bed most of the time and have to crawl to the toilet.

Section 5 – Sitting

A - I can sit in any chair as long as I like without pain. B - I can only sit in my favorite chair as long as I like. C - Pain prevents me from sitting more than one hour. D - Pain prevents me from sitting more than 1/2 hour. E - Pain prevents me from sitting more than 10 minutes. F - Pain prevents me from sitting at all.

Section 6 – Standing

A - I can stand as long as I want without pain. B - I have some pain while standing, but it does not increase with time. C - I cannot stand for longer than one hour without increasing pain. D - I cannot stand for longer than 1/2 hour without increasing pain. E - I cannot stand for longer than 10 minutes without increasing pain. F - I avoid standing, because it increases the pain straight away.

Section 7 – Sleeping

A - I get no pain in bed. B - I get pain in bed, but it does not prevent me from sleeping well. C - Because of pain, my normal night's sleep is reduced by less than one-quarter. D - Because of pain, my normal night's sleep is reduced by less than one-quarter. E - Because of pain, my normal night's sleep is reduced by less than three-quarters. F - Pain prevents me from sleeping at all.

Section 8 – Social Life

A - My social life is normal and gives me no pain. B - My social life is normal, but increases the degree of my pain. C - Pain has no significant effect on my social life apart from limiting my more energetic activities. D - Pain has restricted my social life and I do not go out very often. E - Pain has restricted my social life to my home. F - I have hardly and social life because of the pain.

Section 9 – Traveling

A - I get no pain while traveling. B - I get some pain while traveling, but none of my usual forms of travel make it any worse. C - I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. D - I get extra pain while traveling which compels me to seek alternative forms of travel. E - Pain restricts all forms of travel. F - Pain prevents all forms of travel except that done lying down.

Section 10 – Changing Degree of Pain

A - My pain is rapidly getting better. B - My pain fluctuates, but overall is definitely getting better. C - My pain seems to be getting better, but improvement is slow at present. D - My pain is neither getting better nor worse. E - My pain is gradually worsening. F - My pain is rapidly worsening.

Additional Comments:

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Name:

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Date:

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Signature*

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Score:

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Emergency Contact

Health History

Do you smoke?

Please list and explain. Include dates and treatment received if possible:

Family Medical History

Siblings

Please check All Current and Previous Conditions:

General:

Skin Conditions:

Endocrine System:

Respiratory and Cardiovascular:

Reproductive System:

Muscles and Joints:

Digestive/ Elimination System:

Nervous System:

Cancer or Tumor:

Contract for Care:

Patient Evaluation Chart and Questionnaire

Symptom List

Please list the concerns that brought you in today:

Activities of Daily Living Questionnaire

Work:

Home/Family:

Sleep:

Social/Recreational:

Oswestry Neck Pain Disability Questionnaire

Oswestry Low Back Pain Disability Questionnaire

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