QUESTIONNAIRE TEST

DC - Patient Form 1 (Covington)

Patient's information

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Country

Insurance

Name of primary insured
Name of primary insured
First
Last
Are you covered by Medicare

Emergency Contact

Emergency Contact Name
Emergency Contact Name
First
Last

Pain Assessment

Are you currently in pain?
Rate your pain

Medical History

Check the issues that you have/are experiencing:
Are you currently taking any medications?
Do you have any known medical allergies?
Are you currently under medical treatment?
Have you been admitted to hospital or had surgery within the last 2 years?
Do you use any kind of tobacco
Do you use any kind of illegal drugs or have you ever used them?
How often do you consume alcohol?
Do you have a family physician?
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Country

Family History

Check the conditions that apply to you or any member of your immediate family:

Indicate which of the below you have experienced in the last 1-2 months

Check the conditions that apply to you

Chief Complaint

Check the conditions that apply
Musculoskeletal Pain
Is your condition due to an auto accident?
Have you filed an accident report?
Is your condition due to a job injury?
Have you filed an accident report?

Surgeries or Injuries

Have you been hospitalized in the past?
Have you ever had surgery?
Have you ever had a serious injury?

Women Only:

To your knowledge, ARE YOU PREGNANT?
Our consultation and examination may indicate that x-rays are necessary to accurately diagnose and analyze your condition. Should x-rays be necessary we would like to confirm that you are not pregnant at this time.
If pregnant in the past, were pregnancies normal?
Are you seeing an OB-GYN regularly?

Are you Experiencing any Restriction of the Activities of Daily Living (ADL)

HEALTH CARE: Do you have trouble with any of the following daily tasks?*
ACTIVITIES INVOLVING POSTURE: Are you having trouble with any of the following?*
TRAVEL/DRIVING/ABILITIES: Are you having trouble with any of the following?*
SOCIAL AND RECREATIONAL: Are you having trouble with any of the following?*
SLEEP HABITS: Are you experiencing any of the following conditions?*
POST CONCUSSION: Are you experiencing any of the following conditions?*
HOUSEHOLD RESPONSIBILITIES: Do you have trouble or pain with any of the following tasks?*
SEXUAL FUNCTIONS: Are you having trouble or pain with the following?*
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