Prodigy Chiro-Care and Spinal Rehab - Santa Monica Chiropractor, Los Angeles Custom Orthotics

New Patient Intake

The rating scale below is designed to measure the degree to which several aspects of your life are presently disrupted by your health condition (pain and/or symptoms you may be experiencing). In other words, we would like to know how much your health condition (pain and/or symptoms you may be experiencing) is preventing you from doing what you would normally do. Respond to each category by indicating the overall impact of the pain in your life, not just when the pain is at its worst.

For each of the six categories of daily living listed, PLEASE INDICATE THE NUMBER WHICH BEST DESCRIBES YOUR TYPICAL LEVEL OF ACTIVITIES. 0 means no disability at all and a score of 10 means that all of the activities in which you would normally be involved have been totally disrupted or prevented by your health condition (pain and/or symptoms you may be experiencing).

	Completely Able To Function					Totally Unable To Function
	1	2	3	4	5	6	7	8	9	10
1. FAMILY/HOME RESPONSIBILITIES: activities related to the home or family including chores and duties performed around the house (yard work, dishes, errands, favors for other family members, driving children to school, etc.)
2. RECREATION: hobbies, sports, and other similar leisure time activities.
3. SOCIAL ACTIVITIES: activities which involve participation with friends and acquaintances other than family members including parties, theater, concerts, dining out, and other social functions.
4. OCCUPATION: activities that are a part of or directly related to ones job, including nonpaying jobs as well, such as that of a homemaker or volunteer worker.
5. SELF CARE: activities which involve personal maintenance and independent daily living (taking a shower, driving, getting dressed, etc.)
6. LIFE SUPPORT ACTIVITY: basic life supporting behaviors such as eating, sleeping, breathing.

Name

Address

City

State

Zip

Home Phone

Cell

Pager

E-mail Address

SSN

Date Of Birth

Age

Height

Weight

Gender

Male Female

Civil Status

Single Married Divorced

# of Children

Name of Spouse or Parent

How were you referred to our office?

Employer

Address

Have you had chiropractic care before?

Yes No

If yes, when?

If you are experiencing any health problems, please list your chief
complaints in order of severity.

1. For how long?

2. For how long?

3. For how long?

List other doctors consulted for these
conditions

Name of Family Physician

Do you ever experience any of these complaints while working? Yes No

If yes, describe what activities at work may be causing you to experience these complaints:

Are there any other activities, incidents, or events outside of work that may have caused these complaints? Yes No

If yes, please explain:

If this is due to an injury or accident, what is the date of the injury or accident?

Has this problem been improving, getting worse, or staying the same?

What activities make your condition worse?

Have you ever had any surgeries or hospitalizations? Please list:

Please list any other injuries or illnesses not listed above:

Please indicate medications you are currently taking:
Aspirin/Tylenol Pain Killers Muscle Relaxers
Insulin Tranquilizers Birth Control Pills

Others

Have you been involved in an auto accident in the last 12 months? Yes No

If yes, when?

Health Insurance

Policy Holder

Claims Address

Policy Number

Spouse's Health Insurance

Policy Holder

Claims Address

Policy Number

Preferred Appointment Date
Month
Day
Year

Preferred Appointment Times
1.
2.
3.

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