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HOME
OUR STORY
WHO WE ARE
WHAT TO EXPECT
CONTACT
HOME
Please complete the form below
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Today's Date
*
MM
DD
YYYY
Current work status
*Only applies to auto and workers' comp cases
Regular (no limitation)
Light duty (work restrictions)
Out of work
PLEASE ANSWER ALL QUESTIONS THAT APPLY TO YOU AND YOUR CARE IN OUR OFFICE
Do you have any questions about your condition and or progress to date?
*
Yes
No
If yes please explain
First Complaint
*
How would you classify your improvements so far?
*
Significant
Moderate
Minimal
No Change
On a scale from 0 to 10 with 10 being the "worst pain you have ever felt" and 0 being no pain, how would you rate your discomfort?
*
Second Complaint (if applicable)
How would you classify your improvements so far?
Significant
Moderate
Minimal
No Change
On a scale from 0 to 10 with 10 being the "worst pain you have ever felt" and 0 being no pain, how would you rate your discomfort?
Third Complaint (if applicable)
How would you classify your improvements so far?
Significant
Moderate
Minimal
No Change
On a scale from 0 to 10 with 10 being the "worst pain you have ever felt" and 0 being no pain, how would you rate your discomfort?
Have you noticed any changes in general?
*
Stronger
More alert
More relaxed
More restful sleep
Nothing to report at this time
Things that have improved
*
Sleep
Elimination (1 & 2)
Headaches/Migraines
Circulation
Breathing
Digestion
Extremity pain
Lower blood pressure
Nothing to report at this time
Do you feel the doctor clearly/fully understands your problem?
*
Yes
No
How closely have you followed the doctor's recommended schedule (your adjustment schedule)?
*
0%
25%
50%
75%
100%
Is there anything that you would like more information on or explanation about?
*
My current progress
My care plan (scheduled adjustments)
My insurance benefits
Home exercises and stretches
Nothing at this time
Thank you!
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