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503.246.1881
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New Patient Questionnaire
Patient History Questionnaire
Step 1 of 7
14%
Please complete and submit prior to your appointment.
Name
First
Middle
Last
Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date
MM/DD/YYYY
Date Format: MM slash DD slash YYYY
Age
Date of Birth
Date Format: MM slash DD slash YYYY
Home Phone
Cell Phone
Cell Carrier
Email
Preferred method of contact
Choose One
Home Phone
Cell Phone
Email
Sex
Choose One
Male
Female
Marital Status
Choose One
Single
Married
Divorced
Separated
Widow
Spouse Name
Number of children
Social Security Number
Employer
Occupation
Years at current employment
Ethnicity
Choose One
Native American
Asian
African American
Pacific Islander
Caucasian
Hispanic / Latino
Other
Decline to Specify
Emergency Contact Name
Emergency Contact Number
Primary Care Physician
Primary Care Number
Are your symptoms due to a motor vehicle accident or accident at work?
Choose One
No
Motor vehicle accident
Accident at work
Chief Complaints & Symptoms
Chief Complaint 1
Date of onset
MM/DD/YYYY
Date Format: MM slash DD slash YYYY
Type of pain
Choose One
Achy
Burning
Dull
Sharp
Stiff
Throbbing
Rate your pain on a scale of 1-10
(10 is the worst possible pain)
Choose One
1
2
3
4
5
6
7
8
9
10
How often does the pain occur?
Choose One
Occasional (0-25%)
Intermittent (26-50%
Frequent (51-75%)
Constant (76-100%)
Does the pain radiate anywhere? If yes, where?
What aggravates the symptoms?
What alleviates symptoms?
Do you have another complaint
Choose
Yes
No
Chief Complaint #2
Date of onset
MM/DD/YYYY
Date Format: MM slash DD slash YYYY
Type of pain
Choose One
Achy
Burning
Dull
Sharp
Stiff
Throbbing
Rate your pain on a scale of 1-10
(10 is the worst possible pain)
Choose One
1
2
3
4
5
6
7
8
9
10
How often does the pain occur?
Choose One
Occasional (0-25%)
Intermittent (26-50%)
Frequent (51-75%)
Constant (76-100%)
Does the pain radiate anywhere? If yes, where?
What aggravates the symptoms?
What alleviates symptoms?
Do you have a final complaint?
Choose One
Yes
No
Chief Complaint #3
Date of onset
MM/DD/YYYY
Date Format: MM slash DD slash YYYY
Type of pain
Choose One
Achy
Burning
Dull
Sharp
Stiff
Throbbing
Rate your pain on a scale of 1-10
(10 is the worst possible pain)
Choose One
1
2
3
4
5
6
7
8
9
10
How often does the pain occur?
Choose One
Occasional (0-25%)
Intermittent (26-50%)
Frequent (51-75%)
Constant (76-100%)
Does the pain radiate anywhere? If yes, where?
What aggravates the symptoms?
What alleviates symptoms?
Functional Rating Index
Please select the accurate description of pain associated with the following activities.
Pain Intensity
*
Choose One
0-No Pain
1-Mild Pain
2-Moderate Pain
3-Severe Pain
4-Worst Possible Pain
Sleeping
*
Choose One
0-Perfect Sleep
1-Mildly Disturbed Sleep
2-Moderately Disturbed Sleep
3-Greatly Disturbed Sleep
4-Completely Disturbed Sleep
Personal Care
*
Example: washing, dressing, etc.
Choose One
0-No Pain / No Restrictions
1-Mild Pain / No Restrictions
2-Moderate Pain / Need to go slow
3-Moderate Pain / Need Some Assistance
4-Severe Pain / Need 100% assistance
Travel
*
Example: driving, flying, etc.
Choose One
0-No pain on long trips
1-Mild pain on long trips
2-Moderate pain on long trips
3-Moderate Pain on short trips
4-Severe Pain on short trips
Work
*
Choose One
0-Can do usual work / plus unlimited extra work
1-Can do usual work / No extra work
2-Can do 50% of usual work
3-Can do 25% of usual work
4-Cannot work
Recreation
*
Choose One
0-Can do all activities
1-Can do most activities
2-Can do some activities
3-Can do few activities
4-Cannot do any activities
Frequency of pain
*
Choose One
0-No pain (0% of the day)
1-Occasional pain (25% of the day)
2-Intermittent pain (50% of the day)
3-Frequent pain (75% of the day)
4-Constant pain (100% of the day)
Lifting
*
Choose One
0-No pain with heavy weight
1-Increased pain with heavy weight
2-Increased pain with moderate weight
3-Increased pain with light weight
4-Increased pain with any weight
Walking
*
Choose One
0-No pain at any distance
1-Increased pain after 1 mile
2-Increased pain after 1/2 mile
3-Increased pain after 1/4 mile
4-Increased pain with all walking
Standing
*
Choose One
0-No pain after several hours
1-Increased pain after a half hour
2-Increased pain after 1 hour
3-Increased pain after a half hour
4-Increased pain with any Standing
Past History
Past treatment for current complaint:
Past hospitalizations / Illness: (List type & dates)
Past surgeries: (List type & dates)
Medications / Vitamins
Medication Allergies
General Allergies
Family History
Provide information on who ( immediate family: father, mother, brother, sister) Dates, type and any other details that may be relevant.
Cancer
Stroke
Diabetic
Cardiac
Other
Social History
Tobacco use
Choose One
Never
Former smoker
Light smoker
Heavy smoker
How many packs per day?
Alcohol use
Choose One
None
Casual
Moderate
Heavy
How many drinks per week
Highest education level completed
How often do you exercise?
Never
Daily
Weekly
CAFFEINE (SODA, COFFEE, TEA)
Choose One
1 cup per day
2 cups per day
3 cups per day
4 cups per day
5 cups per day
6 cups per day
7 cups per day
8 cups per day
9 cups per day
10+ cups per day
Review Of Symptoms (Check all boxes that apply)
General
Allergy
Chills
Convulsions
Dizziness
Fainting
Fatigue
Fever
Headache
Sleep Loss
Weight Loss
Depression
Neuralgia
Numbness
Sweats
Tremors
Eyes, Ears, Nose, and Throat
Asthma
Colds
Sore Throat
Hearing Loss
Dental Decay
Gum Trouble
Earache / noises
Ear Discharge
Sinus Infection
Enlarged Glands
Enlarged Thyroid
Nose Bleeds
Failing Vision
Far Sighted
Near Sighted
Hay Fever
Hoarseness
Nasal Obstructions
Musculoskeletal
Arthritis
Bursitis
Foot Trouble
Hernia
Lower Back Pain
Lumbago
Neck Pain / Stiffness
Shoulder blade pain
Painful Tailbone
Poor Posture
Sciatica
Spinal Curvature
Genito - Urinary
Bed Wetting
Blood In Urine
Frequent Urination
Loss of Bladder Control
Kidney Infection or Stones
Painful Urination
Prostate Trouble
Puss in Urine
Painful menstruation
Hot Flashes
Irregular Cycle
Lump(s) in Breast(s)
Cardiovascular
Hardening of Arteries
High Blood Pressure
Low Blood Pressure
Pain Over Heart
Poor Circulation
Rapid Heart Beat
Slow Heart Beat
Swelling of Ankles
Respiratory
Chest Pain
Chronic Cough
Difficult Breathing
Spitting Up Blood
Spitting Up Phlegm
Wheezing
Gastrointestinal
Belching or Gas
Colitis
Colon Trouble
Constipation
Diarrhea
Difficult Digestion
Distention of abdomen
Excessive Hunger
Gall Bladder trouble
Hemorrhoids
Intestinal Worms
Jaundice
Liver Trouble
Nausea
Pain Over Stomach
Poor Appetite
Vomiting
Vomiting Blood
Signature & Acknowledgments
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Hillsdale Chiropractic & Rehabilitation Center of any changes in medical status.
HIPAA Privacy Notice
Click here to access our HIPAA Privacy Notice.
HIPAA Privacy Notice Acknowledgment
*
I acknowledge that I was provided access to a copy of the Notice of Privacy Practices. I understand I can request a copy of this notice at any time. Check box to acknowledge
I acknowledge that I was provided access to a copy of the Notice of Privacy Practices
Name of person signing IF different from patient
First
Middle
Last
Digital Signature
Please Type out Full Name to digitally sign document.
Today's date
Pregnancy Release
This is to certify that to the best of my knowledge I am NOT pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child.
I understand that x-ray can be hazardous to an unborn child. To the best of my knowledge I am NOT pregnant. Dr. Arnot and his associates have my permission to perform an x-ray evaluation if deemed necessary.
Choose
I understand
I do NOT understand
I am MALE
Insurance Information
Please complete for insurance eligibility and benefit determination.
Insurance Comapny
Insurance company contact number
Insurance ID Number
Insurance Group Number
Thank you
Please remember to bring any X-rays or other imaging studies you may have pertaining to your primary complaint.
