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Patient Information (PT 1)

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MaleFemale

Patient Information (PT 2)

SingeMarriedDivorcedPartneredWidowed

Reason For Seeking Care (PT 1)

Injury/Pain RelatedWellness/Health Maintenance
HeadForeheadEar (left)Ear (right)Cheek (left)Cheek (right)
JawTMJNeckShoulder (left)Shoulder (right)
Arm Front (left)Arm Back (left)Arm Front (right)Arm Back (right)

Reason for Seeking Care (PT 2)

Elbow Front (left)Elbow Back (left)Elbow Front (right)Elbow Back (right)Forearm Front (left)Forearm Back (left)Forearm Front (right)Forearm Back (right)Wrist (left)Wrist (right)
Hand Front (left)Hand Back (left)Hand Front (right)Hand Back (right)
ThumbIndexMiddleRingPinky
ThumbIndexMiddleRingPinky
Chest (left)Chest (right)Ribs (left)Ribs (right)Abdomen

Reason for Seeking Care (PT 3)

Thigh Front (left)Thigh Back (left)Thigh Front (right)Thigh Back (right)Knee (left)Knee (right)Leg (left)Leg (right)Ankle (left)Ankle (right)Foot (left)Foot (right)
Big Toe2nd3rd4th5th
Big Toe2nd3rd4th5th
Heel (left)Heel (right)Calf (left)Calf (right)Behind Knee (left)Behind Knee (right)Buttock (left)Buttock (right)

Reason for Seeking Care (PT 5)

Low Back (left)Lower Back (right)Mid Back (left)Mid Back (right)Upper Back (left)Upper Back (right)Scapula (left)Scapula (right)Base of the Skull
012345678910
ConstantlyFrequentlyOccasionallyIntermittently

Reason for Care (PT 6)

AchingBurningCrampingDullSharpTinglingNaggingShootingThrobbingNumbnessStiffness
Getting BetterGetting WorseSame

Medical History (PT 1)

YesNo
ArthritisAsthmaBlood ClotsCancerDiabetes
HepatitisEmphysema/BronchitisHigh Blood PressureEpilepsyStroke
Headaches/MigrainesUlcersHeart Disease/Heart Attack

Medical History (PT 2)

PastPresentNever

Family History

AliveDeceased
AliveDeceased

Review of Systems (PT 1)

FeverWeight Loss > 10 PoundsFatigue
Double VisionDeafnessSinusitisHoarseness
VertigoBlurring of VisionGlassesNose Bleeds
Ear Ringing

Review of Systems (PT 2)

RashSkin Color/Temperature ChangesNail ChangesLesionsMoles
Chest PainPalpitationsShortness of BreathLeg Swelling
Chronic CoughWheezingAsthmaCoughing Up BloodIncreased Sputum Production

Review of Systems (PT 3)

Appetite LossWeight ChangeDiarrheaConstipationAbdominal PainReflux
HesitancyIncontinenceBurning UrinationMenstrual ProblemsPainful UrinationIncreased FrequencyBlood in Urine
FractureSprainArthritisJoint Pain/SwellingMuscle WeaknessMuscle AchesReduce Range of Motion

Review of Systems (PT 4)

Loss of Bowel ControlDizziness/VertigoStrokeSeizuresHeadachesSpeech ProblemsProblems with SwallowingNumbness/Tingling
DepressionHallucinationsSleep DisturbancesAnxietySuicidal Thoughts
Growth/Hair ChangesExcess ThirstDecreased EnergySexual DysfunctionIncreased UrinationCold Intolerance

Review of Systems (PT 5)

Easy BruisingBlood ClotsBleeding Disorders

Health Survey

PoorFairAverageGoodExcellent

Acknowledgement

Chiropractic Informed Consent To Treat (PT 1)

Chiropractic Informed Consent To Treat (PT 2)

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