Foley Health and Fitness Training

First Name*

Last Name*

Email*

Daytime phone #*

Evening phone #*

History of the Present Illness

L - Location of present Complaint:*

M - Was there a particular event that caused the pain or problem? *

Yes

No

• If yes, describe:

N - Are you a new or returning patient?*

New Patient

Returning Patient

O - When did your present complaint begin? (Date)*

P - What aggravates your condition/pain?*

P - What lessens your condition/pain? *

Q - Which of these are you feeling?*

Numbness	Burning	Stabbing	Other
Pins and Needles	Aching	Dull Ache

R - Does the pain/sensation spread or radiate to other areas?*

Yes

No

• If yes, please describe:

S - Please rate your condition/pain on a scale of 0 to 10. (0=no pain 10=most severe pain)

• What is severity of your pain RIGHT NOW? *

• What is the severity of your pain AT ITS BEST? *

• What is the severity of your pain AT ITS WORST?*

T - Is the condition/pain worse during certain times of the day?*

Yes

No

• Since the condition/pain began, has it gotten:*

Better

Worse

Stayed about the same

Is the condition interfering with work?*

Yes

No

Is the condition interfering with sleep?*

Yes

No

Is the condition interfering with your daily routine?*

Yes

No

Is the condition interfering with other activity?*

Yes

No

Is the condition getting progressively worse?*

Yes

No

Other doctors seen for this condition:*

Have you used any home remedies? If yes, please list.*

Are you currently taking any medications? If yes, please list.*

Review of Systems: Musculoskeletal and Nervous

In addition to the above condition/pain do you have any of the following symptoms?*

Additional Information

Date of last physical exam:*

Name of Primary Care Physician:*

Have you been treated for any healthcare condition by a physician in the last year?*

Yes

No

• If yes, describe:

What operations have you had and when?*

Have you had any serious illness or injuries? If any, when did you have them?*

Have you had any broken bones? If yes, which one(s) and when?*

For Female Patients: X-ray Information and Consent

This is to certify to the best of my knowledge I AM NOT PREGNANT

and that Tuck Chiropractic Clinic has my consent to take x-rays.

Date of last menstrual cycle:

Today’s Date:

I have read and understand the disclaimers of this web site.

Please note, submitting this form does not substitute for an office consultation. By submitting this form, no Doctor-Patient relationship is formed with Tuck Chiropractic Clinic. We will require you to come in for an in-office consultation. This will ensure that any care we provide is customized for each patient. It is important to remember that any information received through this website and email cannot be guaranteed to be confidential because of the possibility that a third party could intercept the message. Of course, once our office receives the information, it will be maintained in a confidential manner.

*

By clicking "Save", you have successfully submitted your questionnaire. Thank you for your time and interest in Tuck Chiropractic Clinic. You will be contacted by a member of our team as soon as possible.

Spinal Sports Injury Clinic New Patient Questionnaire