Back_Pain_Form_Packet

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					                                                                                                                3153 Cahaba Heights Road
                                                                                                                Birmingham Alabama 35243
                                                                                                                205.967.0280
                                                                                                                www.birminghamchiropractor.net

                                    CONFIDENTIAL PATIENT INTAKE FORM

NAME: _________________________________________________AGE:______DOB:__________________SS#____________________

HOME ADDRESS: _____________________________________CITY:__________________________ST:_________ZIP_____________

EMPLOYER:___________________________OCCUPATION:______________________E-MAIL___________@___________________

HOME TEL: ________________PAGER/CELL__________________WORK TEL: _______________FAX:_________________________

EMERGENCY CONTACT: ______________________________TEL:____________________PHYSICIAN:________________________

□SINGLE      □MARRIED          □DIVORCED □ WIDOWED □SIGNIFICANT OTHER                                     # CHILDREN__________________
SPOUSE: ________________________________________DOB:___________________TEL:______________SS#:___________________

EMERGENCY CONTACT: _______________________________TEL:_____________________PHYSICIAN:______________________

REFERRED BY:        DR._____________________ PATIENT: ______________________________                      OTHER: _____________________
HEALTH INSURANCE: □NO □YES:_____________________________________________________________________________
_________________________________________________________________________________________________________________
YOU ARE CURRENTLY EXPERIENCING:                  □BACK PAIN         □NECK PAIN          □HEADACHE □OTHER____________________
DESCRIBE□:_____________________________________________________________________________________________
THIS HAPPENED WHEN? __________________ WHERE?                     □HOME □WORK □CAR WRECK □OTHER________________
THIS HAPPENED HOW? ___________________________________________________________________________________________

HAVE YOU HAD THIS OR SIMILAR HAPPEN BEFORE? _______________________________________________________________

WHAT MAKES THE PROBLEM BETTER? ____________________________________________________________________________

WHAT MAKE THE PROBLEM WORSE?                 □SITTING           □STANDING □LYING    □MOVEMENT □REST
                                             □USE               □WALKING   □RUNNING □WORKING □ACTIVITY
                                             □BENDING           □LIFTING  □TWISTING □OTHER_________________________
DESCRIBE THE PAIN OR SENSATION:              □ACHY     □BURNING                   □DULL     □NUMB                      □SHARP
                                             □SHOOTING □SORE                      □STABBING □STIFF                     □TINGLING
DOES THE PAIN RADIATE TO ANOTHER AREA OF THE BODY?                         □NO □YES - WHERE? ________________________________
HOW FREQUENT IS THE PROBLEM?                 □CONSTANT □FREQUENT □INTERMITTENT □OCCASIONAL □ON/OFF
                                             □EVENING ONLY □MORNING ONLY     □WORSE IN THE: □AM or □PM
WHAT % OF THE DAY DO YOU EXPERIENCE THIS PROBLEM?                           □0-25%         □26-50%          □51-75%         □76-100%
OTHER DR.S SEEN FOR THIS CONDITION: □ NO                  □YES:_____________________________________WHEN? _________________
PAST CHIROPRACTIC CARE: □NO □YES DRS NAME: ___________________________________WHEN? __________________
_________________________________________________________________________________________________________________
                                                                  CONSENT
I consent to any physical examination, x-ray study, laboratory procedures, chiropractic or adjunctive therapy or clinic service that is ordered
under the general and specific instructions of the doctor(s).

PATIENT SIGNATURE: ____________________________________________________                        DATE________________________

GUARDIAN SIGNATURE: __________________________________________________                          DATE________________________rev.08.09.07
                                                                                3153 Cahaba Heights Road
                                                                                Birmingham Alabama 35243
                                                                                205.967.0280
                                          PAIN DRAWING                          www.birminghamchiropractor.net




______________________________________________________________________________________________
               On the diagrams below please mark where you are experiencing your symptoms.

                                        X = PAIN / DISCOMFORT
                                       O = NUMBNESS / TINGLING




Patient Signature:_____________________________________________ Date:_______________________rev08.09.07
                                                                                       3153 Cahaba Heights Road
                                                                                       Birmingham Alabama 35243
                                 REVIEW OF SYSTEMS AND HISTORY                         205.967.0280
                                                                                       www.birminghamchiropractor.net



                  Check or circle the appropriate response, please leave blank if it does not apply. ________

Past Medical and/or Family History
(P=patient, M=mom, F=father,
S=Sibling)                                                                 GU
 Heart Disease            PMFS       Social History                       P 1 2 3 Urinary Frequency/Urgency
 Asthma                   PMFS       Caffeine:  No  Light  Heavy       P 1 2 3 Urinary/Burning/Discoloration
 Cancer                   PMFS       Tobacco:  No  Yes                  P 1 2 3 Sexual/Reproductive
 Arthritis                PMFS       Packs Per day________
 Headaches                PMFS       Alcohol:  No  Yes                  Skeletal
 Diabetes                 PMFS       _____________per day/week            P 1 2 3 Morning Stiffness
 MVP                      PMFS        No work      Part time            P 1 2 3 Night Pain
                                       Full Time  School                 P 1 2 3 Neck Pain
 Emphysema                PMFS
                                       Retired      Disability           P 1 2 3 Back Pain
 Anemia                   PMFS                                            P 1 2 3 Joint Pain___________________
 Fibromyalgia             PMFS
 Hernia                   PMFS       Exercise
                                                                           NeuroMuscular
 High BP                  PMFS        Frequently
                                                                           P 1 2 3 Muscle Pain
 Low BP                   PMFS        Occasionally                       P 1 2 3 Weakness
 Alzheimers               PMFS        Rarely                             P 1 2 3 Numbness/Tingling
 Alcoholism               PMFS                                            P 1 2 3 Tremors/Shakes
 Colitis                  PMFS       Review Of Systems                    P 1 2 3 Loss of Consciousness
                                      Please circle if you have had any
 Epilepsy                 PMFS        problems in any of the following:
                                                                           P 1 2 3 Passing out
 Goiter                   PMFS       (P=Past, 1=Mild, 2=Moderate,
 Gout                     PMFS       3=Severe)
                                                                           Females
 High Cholesterol         PMFS                                            Pregnant: Yes No I Don=t Know
 Kidney Disease           PMFS       General Health                        Last Menstrual Cycle_______________
 Leukemia                 PMFS       P 1 2 3 Fatigue/Tiredness             Endometriosis       Hysterectomy
 Lupus                    PMFS       P 1 2 3 Fever/Night Sweats            Tubaligation        C-Section
 Mental Condition         PMFS       P 1 2 3 Trouble Sleeping              Breast Implants     Breast Biopsy
 Obesity                  PMFS       P 1 2 3 Skin Irritation/Rash          Mastectomy
 Rheumatoid Arth.         PMFS       P 1 2 3 Bleeding Disorder
 Ulcers                   PMFS       P 1 2 3 Depression                   Males
 Injuries                 PMFS       P 1 2 3 Anxiety/Tension/Stress        Prostate problems
 Trauma auto/etc.         PMFS
 Other                    PMFS       EENT                                 Present Medication
                                      P123    Vision/Eye                   None List________________________
Surgical History                      P123    Hearing/Ear                  ___________________________________
 Appendectomy       Hemorrhoid      P123    Throat/Swallowing            ___________________________________
                                      P123    Nasal/Sinus                  ___________________________________
 Gall Bladder       Tonsillectomy
                                      P123    Headaches/Face Pain
 Thyroidectomy      Kidney Stone                                         Allergies
 Bladder            Endoscopy       Cardiopulmonary                       Penicillin  Codeine
 Angioplasty        Heart Bypass    P 1 2 3 Breathing                     Aspirin     Sulfa
 Back/Neck Surgery                   P 1 2 3 Swelling/Edema                Other_________________________
 Arthroscopic____________________    P 1 2 3 Chest Pain                    Other_________________________
 Joint Replacement________________
 Fracture________________________    GI
 Cancer Biopsy___________________    P123    Stomach/Abdominal
 Other__________________________     P123    Diarrhea/Constipation
 Other__________________________     P123    Vomiting/Nausea
 Other__________________________     P123    Reflux/Indigestion

Patient Name: _____________________________________________________Date:______________________
                                                       LOW BACK PAIN                                  3153 Cahaba Heights Road
                                                                                                      Birmingham Alabama 35243
                                                                                                      205.967.0280
                                                       QUESTIONNAIRE                                  www.birminghamchiropractor.net




Section 1 - Pain intensity                                        Section 6 - Standing
 I have no pain at the moment.                                    I can stand as long as I want without extra pain.
 The pain is very mild at the moment.                             I have some pain when standing but it does not increase with
 The pain is moderate at the moment.                                time.
 The pain is fairly severe at the moment.                         I can’t stand for longer than one hour without increasing pain.
 The pain is very severe at the moment.                           I can’t stand for longer than 30 min. without increasing pain.
 The pain is the worst imaginable at the moment.                  I can’t stand for longer than 10 min. without increasing pain.
                                                                   I avoid standing because it increases the pain right away.

Section 2 - Personal care (washing, dressing, etc.)               Section 7 – Social Life
 I can look after myself normally without causing extra pain.     My social life is normal and gives me no pain.
 I can look after myself normally but it is very painful.         My social life is normal but increases the degree of pain.
 It is painful to look after myself and I am slow and careful.    Pain has no significant effect on my social life apart from
 I need some help but manage most of my personal care.              limiting my more energetic interest (dancing, etc.)
 I need help every day in most aspects of self care.              Pain has restricted my social life and I do not go out very
 I do not get dressed, wash with difficulty and stay in bed.        often.
                                                                   Pain has restricted my social life to my home.
                                                                   I have hardly any social life because of the pain.
Section 3 - Lifting
 I can lift heavy weights without extra pain.                    Section 8 - Traveling
 I can lift heavy weights but it gives extra pain.                I have no pain while traveling.
 Pain prevents me from lifting heavy weights off the floor        I get some pain while traveling but none of my usual forms of
   but I can manage if they are conveniently positioned, e.g.        travel make it any worse.
   on a table.                                                     I get extra pain while traveling but it does not compel me to
 Pain prevents me from lifting heavy weights but I can              seek alternate forms of travel.
   manage light to medium weights if they are conveniently         I get extra pain while traveling which compels me to seek
   positioned.                                                       alternative forms of travel.
 I can lift only very light weights.                              Pain restricts all forms of travel.
 I cannot lift or carry anything at all.

Section 4 - Walking
 I have no pain walking.                                         Section 9 - Sleeping
 I have some pain walking but it does not increase with           I have no trouble sleeping.
  distance.                                                        My sleep is slightly disturbed. (less than 1 hour sleepless)
 I cannot walk more than one mile without increasing pain.        My sleep is mildly disturbed. (1-2 hours sleepless)
 I cannot walk more than ½ mile without increasing pain.          My sleep is moderately disturbed. (2-3 hours sleepless)
 I cannot walk more than ¼ mile without increasing pain.          My sleep is greatly disturbed. (3-5 hours sleepless)
 I cannot walk at all without increasing pain.                    My sleep is completely disturbed. (5-7 hours sleepless)

Section 5 - Sitting
   I can sit in any chair as long as I like.                     Section 10 – Changing Degree of Pain
   I can only sit in my favorite chair as long as I like.         My pain is rapidly getting better.
   Pain prevents me from sitting for more than one hour.          My pain fluctuates but overall is definitely getting better.
   Pain prevents me from sitting for more than 30 minutes.        My pain seems to be getting better but is slow at present.
   Pain prevents me from sitting for more than 10 minutes.        My pain is neither getting better nor worse.
   I avoid sitting because it increases pain right away.          My pain is gradually worsening.
                                                                   My pain is rapidly worsening.

Please read instructions: This questionnaire has been designed to give the doctor information as to how your pain has affected
your ability to manage in everyday life. Please check the ONE ITEM in each section which most closely applies.
PAIN SEVERITY SCALE: Rate the severity of your pain by checking one box on the following scale:


    0           1          2          3          4          5          6          7          8    9        10
No Pain                                                                                               Excruciating
                                                                                                      Painrev.08.09.07

				
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