First Visit Form

"*" indicates required fields

General Patient Information

First Name*

Last Name*

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Occupation

How Did You Hear About Us?

Age*

Height*

Weight*

Date of Birth*

Pain & Symptoms

The form is very important in your evaluation process. Please fill it out as specifically as possible to provide us with a clear picture of your present pain and functional status.

What is the primary complaint that brings you to us today?*

What is the secondary complaint that brings you to us today?

As a result, I am now having difficulty with:*

Are you currently experiencing pain as a result of these symptoms?*

Do you have any scars? If so, where?

When and how did your symptom(s) begin? Date:*

Past Treatment & Medical History

Have you ever received any of the following treatments for this condition?

Physical Therapy

MFR

Chiropractic

Other

How long did you receive physical therapy treatments and were they helpful?*

How long did you receive MFR treatments and were they helpful?*

How long did you receive chiropractic treatments and were they helpful?*

What other treatment did you receive? How long did you receive these treatments and were they helpful?*

Check the box if you have had any of the following medical conditions*

Other condition(s):*

List past medical history & dates of occurrence. Include surgeries, accidents and other traumas.*

List ALL medications that you are currently taking. Include supplements.

Medication / For treatment of / Amount per day / Effectiveness

Do you have any skin or medication allergies?*

What are your allergies?*

Is there a chance you may be pregnant at this time?*

Do you smoke?*

How much?*

When did you quit?*

Do you experience any of the following do you experience on a DAILY basis?*

Other daily symptoms:*

Do you experience any of the following do you experience on a WEEKLY basis?*

Other weekly symptoms:*

Do you experience any of the following do you experience on a MONTHLY basis?*

Other monthly symptoms:*

Please rate the intensity of your pain with “0” being no pain, “5” is moderate pain, and “10” is unbearable pain.*

Please rate the frequency of your pain with “0” is never, “5” is intermittent, and “10” is constant.*

On a 0 to 10 scale (0 is no pain, 10 is unbearable), how would you rate your pain AT ITS WORST?*

On a 0 to 10 scale (0 is no pain, 10 is unbearable), how would you rate your pain AT ITS BEST?*

On a 0 to 10 scale (0 is no pain, 10 is unbearable), how would you rate your pain MOST OF THE TIME?*

On a 0 to 10 scale (0 is no pain, 10 is unbearable), how would you rate your pain AT NIGHT/SLEEPING?*

At what time of day are your symptoms the WORST?*

At what time of day are your symptoms the BEST?*

Exercise & Sleep

Do you exercise regularly?*

What type of exercise and how often?*

Do you have discomfort, shortness of breath, or pain with exercise?*

On a scale of 1 to 5 with 1 being the most active and 5 being inactive, how would you rate your lifestyle?*

Do you have trouble falling asleep?*

Is your sleep restful?*

Do you find it difficult to lie down?*

Do you find it difficult to come to a sitting position from lying down?*

Do you find it difficult to change positions in bed?*

How many times do you wake in the night?*

How long before you fall back to sleep?*

Daily Activities

What activities Increase your pain?*

What activities Decrease your pain?*

Please estimate the amount of time, on average, you spend in each of the following activities per day.

Sleeping*

Working*

Household Chores*

Sitting at desk*

Talking on phone*

Driving*

Computer Work*

Standing in place*

Playing (specify sports & hobbies)*

Other

How much total time do you tolerate being in a vertical position per day? (e.g. sitting, standing, walking, driving)*

If you need to rest during the day, how often?

And what is the total time (in hours)?

How much total time do you tolerate being in a horizontal position per day? (e.g. reclining, laying down, sleeping)

How many minutes can you walk for before needing to rest?*

How many minutes can you sit for before needing to to change positions/get up?*

How many minutes can you stand for before needing to sit?*

Do you have trouble getting up from a chair?*

Do you have trouble putting on your shoes and socks?*

Do you have difficulty climbing stairs?*

List all the Tasks/Activities that you have difficulty performing and your tolerance for each.*

Activity / Tolerance (minutes/hours)

Functional Ability

On a scale of 0% to 100%, how functional are you on a GOOD DAY?*

On a scale of 0% to 100%, how functional are you on a BAD DAY?*

How do you Rate your Stress Level on a scale of 0 – 10 (10 is the most intense)?*

What are your top 3 Stressors?*

List the activities that you would like to be able to do as a result of therapy.*

Activity / How Often or Duration / By When

Practices & Policies

Client Signature*

Today's Date