NEW PATIENT FORMS PAGE 2 SYMPTOM SURVEY
Family Chiropractic Clinic of Hillsborough
303 Omni Dr. Hillsborough, NJ 08844 908-359-0123-p, 908-359-0143-fax or email the form to familychiro@att.net
Patient Name:___________________________________ Date:_______________________ To assist your doctors in obtaining an early understanding of your state of health please describe, in the spaces below, the present complaint(s) for which you have come to this clinic for care. Type of symptoms A=Achiness, B=Burning, P=Pain, N=Numbness, S=Stabbing Pain, T=Tingling etc.
Head_________________________________________________________________________
Neck_________________________________________________________________________
Thoracic/Upper/Mid Back________________________________________________________
Low Back_____________________________________________________________________
Pelvis________________________________________________________________________
Shoulder(s)____________________________________________________________________
Upper Arm(s)__________________________________________________________________
Elbow(s)______________________________________________________________________
Lower Arm(s)__________________________________________________________________
Wrist(s)______________________________________________________________________
Hand(s)______________________________________________________________________
Finger(s)_____________________________________________________________________
Hip(s)________________________________________________________________________
Upper Leg(s)__________________________________________________________________
Knee(s)______________________________________________________________________
Lower Leg(s)__________________________________________________________________
Ankle(s)______________________________________________________________________
Arch(es)______________________________________________________________________
Foot(feet)_____________________________________________________________________
Toe(s)________________________________________________________________________ Please list all medications you are currently taking and what you are taking them for, including (Prescription, birth control, over the counter, Vitamins, minerals, herbs etc.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Please circle each of your pains and tingling with area abbreviations on the scales below
Abbreviations: Neck = N, Back = B, Head = H, Upper Extremity = UE = All parts of the arm and hand, Lower Extremity = LE = All parts of the leg and foot, P = Pain T = Tingling, Pins & Needles Or Numbness. 0=No Pain or Tingling 10=Terrible
|__0__|__1__|__2__|__3__|__4__|__5__|__6__|__7__|__8__|__9__|__10__|
Please circle the frequency, in percent, for each pain or tingling with area of pain of tingling indicated by abbreviations
|__0__|__10__|__20__|__30__|__40__|__50__|__60__|__70__|__80__|__90__|__100%__|
Your Primary Dr. Name:_________________________________________________________
Address:_____________________________________________________________________
Phone #____________________Fax #_________________Last appointment______________ Reason for visit________________________________________________________________
OBGYN Dr. Name_____________________________________________________________ Address:_____________________________________________________________________
Phone #____________________Fax #_________________Last appointment______________ Reason for visit________________________________________________________________
Orthopedist/Neurologist/Rheumatologist etc_________________________________________
Address:_____________________________________________________________________
Phone #____________________Fax #_________________Last appointment______________ Reason for visit________________________________________________________________