← Return to forms & documents Patient Health Condition Form Intake form for acupuncture, chiropractic, and physiotherapy visits Patient Information Name * First Name Last Name Height Please note unit (Ft, cm, etc.) Weight Please note unit (Lbs, Kgs, etc.) What is your major symptom/problem? * When did your symptoms begin? Have you had this problem before? Is your condition getting progressively worse? Yes No This problem is: Constant Comes and goes Please select the closest to your severity of pain * No pain (0) 1 2 3 4 5 6 7 8 9 Severe pain (10) How does it feel? Burning Aching Swelling Sharp Stiff Tingling Throbbing Shooting Dull Other What makes your condition better? What makes your condition worse? Does it interfere with your: Work Sleep Daily Routine Recreation PAST INJURIES Have you had any: Automobile accidents Please note the date(s) and any relevant details Surgeries Please note the date(s) and any relevant details Broken bones Please note the date(s) and any relevant details Falls/Head injuries Please note the date(s) and any relevant details STRESSORS Are any of the following stressors a constant in your life: Smoking Please note your intake – ex: packs/day Alcohol Please note your intake – ex: drinks/week Coffee/Caffeine Please note your intake – ex: cups/day High stress level Please note the reason & severity FEMALES Are you pregnant? Yes No Please list any medications you are taking: Activities/movements that are painful to perform: Sitting Standing Walking Bending Lying Down Driving Reading Getting Up CONDITIONS Select any of the following conditions you have had: AIDS/HIV Allergies Anxiety/Depression Arm/Shoulder Pain Arthritis Asthma Bladder problems Cancer Chronic fatigue Deafness Diabetes Digestion problems Earache Ear ringing Epilepsy Headaches/Migraines Heart Disease Hemorrhoids Herniated disk High blood pressure Insomnia Irregular cycle Kidney problems Leg pain Low back pain Neck pain Osteoporosis Poor circulation Prostate problems Rheumatoid Arthritis Sciatica Shingles Sinus infection Stroke Thyroid problems TMJ Venereal disease Vertigo/Dizziness Do you have a family history of: Cancer Diabetes Heart problems High blood pressure AGREEMENT By agreeing, you confirm that: * I confirm that the information I have provided in regards to my current condition and past health history are to the best of my knowledge. I also acknowledge that it is my responsibility to update the clinic in regards to any changes in my health condition. I also authorize the release of my medical condition to my family physician. Agree Disagree Thank you!We’ve received your form, see you at your appointment!
