OUTREACH PATIENT EVALUATION FORM

Personal Information:

Name: ___________________________      Sex: M   F             Date of Birth: __________________

Address: _________________________        City: _________________       State/Zip: _________

E-mail Address: _____________________________________________________________

Primary Care Physician: _______________________________        Phone #: _______________

Address: __________________________________________       Date of Last Visit: _________

 

History:

1. My chief compliant is: ___________________________________________________

2. Describe your present symptoms if any: _______________________________________

3. When did the pain/illness of injury start? ______________________________________

4. What makes it better? _______________________    What makes it worse: ____________

5. Do you have pain before, during or after activity (circle all that apply)?

6. Have you had chiropractic/massage care before? …………………………………..Yes / No

7. Have you been adjusted/manipulated “full spine?” (neck, midback, lowback) ………….Yes / No

8. Other Comments: ______________________________________________________

9. Do you have any chiropractic or other health questions you would like to have answered? Yes / No

_______________________________________________________________________________

Patient Initial: ______

 

Review of Systems:

Do you have or have you had problems with the following? (Check all that apply)

□Easy bruising/bleeding                   □Low back Pain/Injury                       □Cancer                                 □Fever Chills

□Heart/circulation                             □Genito-urinary system                     □Eyes/Ears/Nose/Throat        □Strains/Sprains

□High blood pressure                       □Osteoporosis                                   □Thyroid                                 □Weight Changes

□Neck Pain/Injury                             □Arthritis                                            □Chest Pains                          □Head Trauma

□Stomach/Digestion                         □Lungs/Respiration                            □Skin/Hair/Nails                     □Other: ______

□Headaches                                     □Diabetes                                          □Kidney Disease

□Surgery (ies) (List): __________________________________________________________________

□Medications (including Blood Thinners &/or Birth Control Pills): ___________________________________

________________________________________________________________________________

Patient Initial: _______