CURRENT COMPLAINTS - Compass Chiropractic



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CURRENT COMPLAINTS

Patient’s Name: _______________________ Date: _____________

Please indicate the current complaints you are experiencing by marking the areas on the image below and providing details using the sections that follow.

1. headaches

2. Neck

3. Upper back

4. Mid Back

5. Lower Back

6. Hip

7. Buttock

8. Shoulder

9. Arm

10. Elbow

11. Forearm

12. Wrist

13. Hand

14. Fingers

15. Leg

16. Knee

17. Calf

18. Shin

19. Ankle

20. Foot

21. Toes

22. Chest

23. Ribs

24. Abdomen

25. Pelvis/Groin Please fill out a separate Area of Complaint for each area you’re experiencing pain

|Area of Complaint | |

| |Date of onset:_______________ |

|Location |[pic] Left [pic] Right [pic] Both [pic] Center |

|Pain Ratings |[pic] 0 [pic] 1 [pic] 2 [pic] 3 [pic] 4 [pic] 5 [pic] 6 [pic] 7 [pic] 8 [pic] 9 [pic] 10 (Excruciating) |

|Frequency |[pic] Infrequent < 25% [pic] Occasional 25% to 50% [pic] Frequent 50% to 75% [pic] Constant > 75% |

|Pain Type |[pic] No Pain [pic] Pain [pic] Numbness [pic] Tingling [pic] Muscle Spasms [pic] Burning |

|Severity | [pic] Mild [pic] Mild to Moderate [pic] Moderate [pic] Moderate to Severe [pic] Severe |

|What makes it better? | [pic] Medication [pic] Lying Down [pic] Standing [pic] Sitting [pic] Stretching [pic] Range of Motion [pic] Nothing |

|What makes it worse? |[pic] Brig [pic] Movements [pic] Bending [pic] Twisting [pic] Weight Bearing [pic] Movements |

| |[pic] Wat [pic] Neck flexion [pic] Sneezing [pic] Sitting [pic] Standing [pic] Walking |

| |[pic] Chewing [pic] Yawning [pic] Opening mouth [pic] Closing mouth |

| |[pic] Range of motion [pic] pushing/pulling [pic] Lifting |

| |[pic] Watching T.V. [pic] Reading [pic] Working [pic] Driving [pic] Housework |

| |[pic] Bright lights [pic] Loud Noises |

|Does the pain |Upper Body |[pic] Nec [pic] Head [pic] Forehead [pic] Back of head [pic] Right side of head [pic] Left side of head |

|radiate to any | |[pic] Neck [pic] Right Ear [pic] Left Ear [pic] Right Eye [pic] Left Eye |

|other locations? | |[pic] Face [pic] Right Jaw [pic] Left Jaw |

| | |[pic] Right Upper back [pic] Left Upper back [pic] Right Shoulder [pic] Left Shoulder |

| | |[pic] Right Chest [pic] Left Chest [pic] Right Ribs [pic] Left Ribs |

| |Mid Body | [pic] Right Mid back [pic] Left Mid back [pic] Right Lower back [pic] Left Lower back |

| | |[pic] Right Hip [pic] Left Hip [pic] Right Buttock [pic] Left Buttock [pic] Groin |

| | |[pic] Right Arm [pic] Left Arm [pic] Right forearm [pic] Left forearm |

| | |[pic] Right hand [pic] Left hand [pic] Right fingers [pic] Left fingers |

| |Lower Body | [pic] Right Thigh [pic] Left Thigh [pic] Right Knee [pic] Left Knee |

| | |[pic] Right Calf [pic] Left Calf [pic] Right Toes [pic] Left Toes |

| | |[pic] Right Foot [pic] Left Foot [pic] Right Toes [pic] Left Toes |

|Described as | [pic] Aching [pic] Dull [pic] Sharp [pic] Stabbing [pic] Throbbing |

|At it’s worst | [pic] Morning [pic] Afternoon [pic] Evening [pic] Night After Activities: [pic] Light [pic] |

| |Moderate |

|Associated with |[pic] Dizz [pic] Dizziness [pic] Nausea [pic] Visual Problems [pic] Ringing/Buzzing ears |

| |[pic] Bright light [pic] Sensitivity [pic] Loss of balance |

|Comments | |

| | |

| | |

| | |

|Area of Complaint | |

| |Date of onset:______________ |

|Location |[pic] Left [pic] Right [pic] Both [pic] Center |

|Pain Ratings |[pic] 0 [pic] 1 [pic] 2 [pic] 3 [pic] 4 [pic] 5 [pic] 6 [pic] 7 [pic] 8 [pic] 9 [pic] 10 (Excruciating) |

|Frequency |[pic] Infrequent < 25% [pic] Occasional 25% to 50% [pic] Frequent 50% to 75% [pic] Constant > 75% |

|Pain Type |[pic] No Pain [pic] Pain [pic] Numbness [pic] Tingling [pic] Muscle Spasms [pic] Burning |

|Severity | [pic] Mild [pic] Mild to Moderate [pic] Moderate [pic] Moderate to Severe [pic] Severe |

|What makes it better? | [pic] Medication [pic] Lying Down [pic] Standing [pic] Sitting [pic] Stretching [pic] Range of Motion [pic] Nothing |

|What makes it worse? |[pic] Brig [pic] Movements [pic] Bending [pic] Twisting [pic] Weight Bearing [pic] Movements |

| |[pic] Wat [pic] Neck flexion [pic] Sneezing [pic] Sitting [pic] Standing [pic] Walking |

| |[pic] Chewing [pic] Yawning [pic] Opening mouth [pic] Closing mouth |

| |[pic] Range of motion [pic] pushing/pulling [pic] Lifting [pic] Bright lights [pic] Loud Noises |

| |[pic] Watching T.V. [pic] Reading [pic] Working [pic] Driving [pic] Housework |

|Does the pain |Upper Body |[pic] Nec [pic] Head [pic] Forehead [pic] Back of head [pic] Right side of head [pic] Left side of head |

|radiate to any | |[pic] Neck [pic] Right Ear [pic] Left Ear [pic] Right Eye [pic] Left Eye |

|other locations? | |[pic] Face [pic] Right Jaw [pic] Left Jaw |

| | |[pic] Right Upper back [pic] Left Upper back [pic] Right Shoulder [pic] Left Shoulder |

| | |[pic] Right Chest [pic] Left Chest [pic] Right Ribs [pic] Left Ribs |

| |Mid Body | [pic] Right Mid back [pic] Left Mid back [pic] Right Lower back [pic] Left Lower back |

| | |[pic] Right Hip [pic] Left Hip [pic] Right Buttock [pic] Left Buttock [pic] Groin |

| | |[pic] Right Arm [pic] Left Arm [pic] Right forearm [pic] Left forearm |

| | |[pic] Right hand [pic] Left hand [pic] Right fingers [pic] Left fingers |

| |Lower Body | [pic] Right Thigh [pic] Left Thigh [pic] Right Knee [pic] Left Knee |

| | |[pic] Right Calf [pic] Left Calf [pic] Right Toes [pic] Left Toes |

| | |[pic] Right Foot [pic] Left Foot [pic] Right Toes [pic] Left Toes |

|Described as | [pic] Aching [pic] Dull [pic] Sharp [pic] Stabbing [pic] Throbbing |

|At it’s worst | [pic] Morning [pic] Afternoon [pic] Evening [pic] Night After Activities: [pic] Light [pic] |

| |Moderate |

|Associated with |[pic] Dizz [pic] Dizziness [pic] Nausea [pic] Visual Problems [pic] Ringing/Buzzing ears |

| |[pic] Bright light [pic] Sensitivity [pic] Loss of balance |

|Comments | |

| | |

|Area of Complaint | |

| |Date of onset:______________ |

|Location |[pic] Left [pic] Right [pic] Both [pic] Center |

|Pain Ratings |[pic] 0 [pic] 1 [pic] 2 [pic] 3 [pic] 4 [pic] 5 [pic] 6 [pic] 7 [pic] 8 [pic] 9 [pic] 10 (Excruciating) |

|Frequency |[pic] Infrequent < 25% [pic] Occasional 25% to 50% [pic] Frequent 50% to 75% [pic] Constant > 75% |

|Pain Type |[pic] No Pain [pic] Pain [pic] Numbness [pic] Tingling [pic] Muscle Spasms [pic] Burning |

|Severity | [pic] Mild [pic] Mild to Moderate [pic] Moderate [pic] Moderate to Severe [pic] Severe |

|What makes it better? | [pic] Medication [pic] Lying Down [pic] Standing [pic] Sitting [pic] Stretching [pic] Range of Motion [pic] Nothing |

|What makes it worse? |[pic] Brig [pic] Movements [pic] Bending [pic] Twisting [pic] Weight Bearing [pic] Movements |

| |[pic] Wat [pic] Neck flexion [pic] Sneezing [pic] Sitting [pic] Standing [pic] Walking |

| |[pic] Chewing [pic] Yawning [pic] Opening mouth [pic] Closing mouth |

| |[pic] Range of motion [pic] pushing/pulling [pic] Lifting [pic] Bright lights [pic] Loud Noises |

| |[pic] Watching T.V. [pic] Reading [pic] Working [pic] Driving [pic] Housework |

|Does the pain |Upper Body |[pic] Nec [pic] Head [pic] Forehead [pic] Back of head [pic] Right side of head [pic] Left side of head |

|radiate to any | |[pic] Neck [pic] Right Ear [pic] Left Ear [pic] Right Eye [pic] Left Eye |

|other locations? | |[pic] Face [pic] Right Jaw [pic] Left Jaw |

| | |[pic] Right Upper back [pic] Left Upper back [pic] Right Shoulder [pic] Left Shoulder |

| | |[pic] Right Chest [pic] Left Chest [pic] Right Ribs [pic] Left Ribs |

| |Mid Body | [pic] Right Mid back [pic] Left Mid back [pic] Right Lower back [pic] Left Lower back |

| | |[pic] Right Hip [pic] Left Hip [pic] Right Buttock [pic] Left Buttock [pic] Groin |

| | |[pic] Right Arm [pic] Left Arm [pic] Right forearm [pic] Left forearm |

| | |[pic] Right hand [pic] Left hand [pic] Right fingers [pic] Left fingers |

| |Lower Body | [pic] Right Thigh [pic] Left Thigh [pic] Right Knee [pic] Left Knee |

| | |[pic] Right Calf [pic] Left Calf [pic] Right Toes [pic] Left Toes |

| | |[pic] Right Foot [pic] Left Foot [pic] Right Toes [pic] Left Toes |

|Described as | [pic] Aching [pic] Dull [pic] Sharp [pic] Stabbing [pic] Throbbing |

|At it’s worst | [pic] Morning [pic] Afternoon [pic] Evening [pic] Night After Activities: [pic] Light [pic] |

| |Moderate |

|Associated with |[pic] Dizz [pic] Dizziness [pic] Nausea [pic] Visual Problems [pic] Ringing/Buzzing ears |

| |[pic] Bright light [pic] Sensitivity [pic] Loss of balance |

|Comments | |

________________________________________________ Signature

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Office Financial Policy

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Medical History Information

|Last Name: |( Mr. |( Miss |Marital status (circle one) |

| |( Mrs. |( Ms. | |

|First Name: |Middle: | | |Single / Mar / Div / Sep / Widow|

|Email: |Birth date: |Age: |Sex: |

|Address: |City: |State: |

|ZIP Code: |Social Security No.: |Home Phone: |

|Occupation: |Employer: |Employer phone: |

|Medical Care Information |

| Do You Have a Family Doctor?: No Yes, Name of Doctor: |

| Address: |City: |State: |ZIP Code: |

| Date of last Visit: / / |Date of last exam: / / |

| Do You Have a Family Chiropractor?: No Yes, Name of Chiropractor: |

| Address: |City: |State: |ZIP Code: |

| Date of last Visit: / / |Date of last exam: / / |

|Have you had surgeries in the last 5 Years: Yes No If yes, Last Surgery Date: |

|Reason for Surgery: |

| |

|Are your pregnant? (please circle) Yes No Maybe |

|Present illness /Conditions: | |

| AIDS |

|Family History of illness: | |

| AIDS |

| | |

|Type of Cancer: |Breast Lung Other: |

|Social History: | |

|Alcohol? No Yes |Cigarettes? No Yes |Caffeine? No Yes |Exercise? No Yes Hours per week? |

|Drinks per week? |Packs per day? |Drinks per day? |(circle one) Light / Moderate / Strenuous |

|Misc.: |

Signature: __________________________________________ Date: _________

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

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