PATIENT CONSULTATION WORKSHEET

PATIENT CONSULTATION WORKSHEET Today s Date: Name: Referred By: Birthdate: Address: City: State: Zip: Home Phone: Work: Ext: Cell Phone: E-Mail Address: Best way for us to keep in touch with you (check one): Home Phone Cell Phone Work Phone E-Mail Text Message- Cell provider: (normal text msg fees from your provider may apply) Gender: Male Female Social Security Number: - - Marital Status: Single Married Partnered Divorced Widowed Employer(s): Address: City: State: Zip: Patient s Occupation(s): Spouse s Name: Spouse s Employer: Employer s Address: City: State: Zip: Spouse s Work Phone: Emergency Contact: Spouse s Birthdate: Emergency Phone: CONSENT TO TREATMENT OF A MINOR/CHILD I hereby authorize the Doctors of Bellevue Chiropractic Group to administer Chiropractic care as deemed necessary to my son/daughter (circle one): Name of Child/Minor: Parent or legal guardian Signature: Date:

HISTORY When did condition(s) begin? How did condition(s) begin? Indicate all that apply: Gradual onset Twisting Lifting Bending Reaching Fall Direct blow Pushing Pulling Running Recreational injury Vehicle accident Work related Non-work related I do not know. Other: Do you feel this was the fault of another person or party? If yes, have you retained an attorney to assist you with your claim? If yes, what is the name and phone number of the attorney? Yes / No Yes / No List your current condition(s) or symptom(s) in the order of decreasing severity: 1. 2. 3. 4. 5. 6. 7. 8.

PRIOR MEDICAL CARE: Please list all surgeries and approximate dates: Date Type of Surgery Post-operative complication(s) Of the following diagnostic procedures, please indicate those you have undergone: Study No Yes Date Results Reg. Spine x-rays MRI CT Scan Bone Scan EMG Nerve Block Other: N/A History of fractures: Date Fracture Complications

Please list the physicians you have consulted for this (these) condition(s): Type of doctor Name of Doctor Location Approximate dates Please indicate each of the following methods of care you have received and its effect: Treatment Yes Helped No change Made Worse Acupuncture Aerobic exercise Anti-depressant medications Anti-inflammatory medications Bed rest Biofeedback Chiropractic adjustments Electric Stimulation Epidural injections Facet joint injections Gravity inversion Heat Ice Local injections Massage Muscle relaxants Narcotic pain medications Osteopathic manipulation Rigid back brace Soft back brace Strengthening exercise TENS unit Traction Ultrasound Other: Other: Please circle the treatments (above) that you are currently receiving.

Who is your primary physician? Phone: ( ) When was your last complete checkup or exam? During the past year have you had: SYMPTOMS Unexplained fevers? Night Sweats? Weight loss of 10 lbs. Or more? Loss of appetite? Excessive fatigue? Problems with depression? Difficulty sleeping? Unusual stress in home life? Unusual stress in work life? Easy bruising? Excessive bleeding? Lumps in neck, armpits or groin? Chest pain or tightness? Persistent or unusual cough? Trouble breathing with exercise? Coughing up blood? Swollen ankles? Stomach pain? Change in bowel habits? Persistent diarrhea? Excessive constipation? Dark black stools? Blood in stools? Pain or burning when urinating? Difficulty urinating? Blood in urine? Need to urinate more at night? Please list any other medical problems you may have: EXPLANATION

STATUS OF CONDITION(S): Using the following scale, please circle your response to each of the questions below. Zero (0) represents no pain/discomfort. Ten (10) represents the most pain/discomfort possible. NO PAIN MOST PAIN What is your least pain? 0 1 2 3 4 5 6 7 8 9 10 What is your worst pain? 0 1 2 3 4 5 6 7 8 9 10 What is your pain now? 0 1 2 3 4 5 6 7 8 9 10 Since the onset, indicate the course your condition(s) has taken or provide your own description. Dramatically improved Somewhat improved No change Somewhat worsened Dramatically worsened Not applicable Other: ACTIVITIES OF DAILY LIVING: Because of your condition, you may find some of your regular duties or activities difficult. Please indicate which of the following statements describe how you have been affected by your condition. Please indicate all that apply. I stay at home most of the time because of my condition(s). I am not able to do the jobs that I normally do around the house because of my condition(s). I avoid heavy jobs around the house because of my condition(s). I use a handrail to get up a flight of stairs because of my condition(s). I go up a flight of stairs more slowly than usual because of my condition(s). I stay in bed most of the time because of my condition(s). I find it difficult to turn over in bed because of my condition(s). I sleep less well because of my condition(s). I lie down to rest more often because of my condition(s). I sit down most of the day because of my condition(s). I have to hold on to something to get out of a chair because of my condition(s). I have other people do things for me because of my condition(s). I walk more slowly than usual because of my condition(s). I only walk short distances because of my condition(s). I only stand up for short periods of time because of my condition(s). I am uncomfortable most of the time because of my condition(s). I try to become more comfortable by changing positions frequently because of my condition(s). I am aided by someone else when I am dressing because of my condition(s). I get dressed more slowly because of my condition(s). I am more irritable and bad tempered with people than usual because of my condition(s). My appetite is not very good because of my condition(s).

How much time during an average day are you affected by your condition(s)? Less than one (1) hour per day. Between four (4) and eight (8) hours per day. Between eight (8) and twelve (12) hours per day. Between twelve (12) and twenty-four (24) hours per day. Almost anytime I am not lying down. How many days out of an average week are you affected by your condition(s)? Indicate the worst and best times of day for your condition(s): Best Worst N/A Upon first awakening Morning Mid-Day Afternoon Evening During my sleep How often do you have to stop your activities and sit or lie down due to your condition(s)? Almost all day Several times per day Occasionally Never Approximately once per day Other: List specific activities that worsen your condition(s): 1. 3. 2. 4. List activities that relieve your condition(s): 1. 3. 2. 4. What are some of your usual recreational activities? Place an X in front of those in which you can no longer participate because of your condition(s). 1. 3. 2. 4.

LIFESTYLE HISTORY: Do you (or have you ever) smoked cigarettes, cigars, a pipe or used chewing tobacco? If yes, how many years? If yes, what is the frequency during an average day? If yes, what age were you when you quit? N/A because I have not quit. Yes / No Do you drink alcoholic beverages? Yes / No If yes, for how many years? If yes, average number of drinks per week: Have you ever used alcohol to control your pain? Yes / No HISTORY OF PREVIOUS CONDITION(S): Prior to this current condition(s), have you ever had a similar condition that required professional help? Yes / No If yes, briefly explain: Other than this current condition, have you ever had any previous neck or back symptoms, that required professional help? Yes / No If yes, briefly explain: Were any of these above conditions the result of an industrial injury or motor vehicle accident? If yes, briefly explain: Yes/ No Please list any dates off work that exceed two (2) weeks for these previous injuries: Were you compensated for these injuries through disability coverage or a legal settlement? Yes / No Excluding the current condition(s), how many episodes of neck or back pain have you had in the last two years? OCCUPATIONAL HISTORY: How physically demanding is your job? Very heavy (frequently lifting 100 or more pounds) Heavy (frequently lifting 60 100 pounds) Moderate (frequently lifting 30 60 pounds) Light (frequently lifting 10 30 pounds) Sedentary (essentially no lifting) How satisfied are you with your job? Very Satisfied Satisfied Dissatisfied It is the worst job in the world. When was the last time you worked? Today Yesterday Last Week Last Month Last Year Other

Your work status at the time of onset of this condition(s): Regular duties (full time) Temporary light duties Permanent light duties Not currently in work force On disability or time loss On public assistance Other: Has you employer treated you fairly? Yes / No Has any one in your family been on disability? Their relationship to you: Yes / No FEMALES ONLY: Indicate all that apply: Vaginal bleeding other than the time of menstrual cycle. Obstetrician/Gynecological exam within the last two years. Currently having painful menstrual cycles that interfere with daily life. Back pain increases with menstrual cycle. I have other menstrual problems: I may be or I am currently pregnant. Approximate due date:

Low Back Pain and Disability Questionnaire (revised Oswestry) Name: Date: This questionnaire has been designed to give the health care provider information as to how your BACK pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box which most closely describes your problem today. SECTION 1 PAIN INTENSITY The pain comes and goes and is very mild. The pain is mild and does not vary much. The pain comes and goes and is moderate. The pain is moderate and does not vary much. The pain comes and goes and is very severe. The pain is severe and does not vary much. SECTION 2 PERSONAL CARE I would not have to change my way of washing or dressing in order to avoid pain. I do not normally change my way of washing and dressing even though it causes some pain. Washing and dressing increase the pain but I manage not to change my way of doing it. Washing and dressing increase the pain and I find it necessary to change my way of doing it. Because of the pain I am unable to do some washing and dressing. Because of the pain I am unable to do any washing and dressing without help. SECTION 3 LIFTING I can lift heavy weights without extra pain. I can lift heavy weights but it causes extra pain. Pain prevents me from lifting heavy weights off the floor. Pain prevents me from lifting heavy weights off the floor, but I manage if they are conveniently positioned (e.g. on a table). Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can only lift very light weights at the most. SECTION 4 WALKING I have no pain on walking. I have some pain on walking but it does not increase with distance. I cannot walk more than one mile without increasing pain. I cannot walk more than ½ mile without increasing pain. I cannot walk more than ¼ mile without increasing pain. I cannot walk at all without increasing pain. SECTION 5 SITTING I can sit in any chair as long as I like. I can sit in my favorite chair as long as I like. Pain prevents me from sitting more than one hour. Pain prevents me from sitting more than ½ hour. Pain prevents me from sitting more than 10 minutes. I avoid sitting because it increases my pain straight away. SECTION 6 S TANDING I can stand as long as I want without pain. I have some pain on standing but it does not increase with time. I cannot stand for longer than one hour without increasing pain. I cannot stand for longer than ½ hour without increasing pain. I cannot stand for longer than 10 minutes without increasing pain. I avoid standing because it increases the pain straight away. SECTION 7 SLEEPING I get no pain in bed. I get pain in bed but it does not prevent me from sleeping well. Because of pain my normal night s sleep is reduced by less than ¼. Because of pain my normal night s sleep is reduced by less than ½. Because of pain my normal night s sleep is reduced by less than ¾. Pain prevents me from sleeping at all. SECTION 8 SOCIAL LIFE My social life is normal and gives me no pain. My social life in normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests (e.g. dancing, etc). Pain has restricted my social life and I do not go out very often. Pain has restricted my social life to my home. I have hardly any social life because of the pain. SECTION 9 TRAVELING I get no pain while traveling. I get some pain while traveling but none of my usual forms of travel make it any worse. I get extra pain while traveling but it does not compel me to seek alternative forms of travel. I get extra pain while traveling which compels me to seek alternative. Pain restricts all forms of travel. Pain prevents all forms of travel except that done lying down. SECTION 10 CHANGING DEGREE OF PAIN My pain is rapidly getting better. My pain fluctuates but overall is definitely getting better. My pain seems to be getting better but improvement is slow at present. My pain is neither getting better or worse. My pain is gradually worsening. My pain is rapidly worsening.

Neck Pain and Disability Index (Vernon-Minor) Name: Date: This Questionnaire has been designed to give the health care provider information as to how your NECK pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box which most closely describes your problem today. SECTION 1 PAIN INTENSITY I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment. SECTION 2 PERSONAL CARE (washing, dressing, etc.) I can look after myself normally without causing pain. I can look after myself normally but it causes extra pain. It is painful to look after myself and I am slow and careful. I need some help but manage most of my personal care. I need help every day in most aspects of self care. I do not get dressed, I wash with difficulty and I stay in bed. SECTION 3 LIFTING I can lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example on a table. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can lift very light weights. I cannot lift or carry anything at all. SECTION 4 READING I can read as much as I want to with no pain in my neck. I can read as much as I want to with slight pain in my neck. I can read as much as I want to with moderate pain in my neck I can hardly read at all because of severe pain in my neck. I cannot read at all. SECTION 5 HEADACHES I have no headaches at all. I have slight headaches which come infrequently. I have moderate headaches which come infrequently. I have moderate headaches which come frequently. I have severe headaches which come frequently. I have headaches almost all of the time. SECTION 6 CONCENTRATION I can concentrate fully when I want to with no difficulty. I can concentrate fully when I want to with slight difficulty. I have a fair degree of difficulty in concentrating when I want to. I have a lot of difficulty in concentrating when I want to. I have a great deal of difficulty in concentrating when I want to. I cannot concentrate at all. SECTION 7 WORK I can do as much work as I want to. I can do my usual work but no more. I can do most of my usual work but no more. I cannot do my usual work. I can hardly do any work at all. I can t do any work at all. SECTION 8 DRIVING I can drive my car without any neck pain. I can drive my car as long as I want with slight pain in my neck. I can drive my car as long as I want with moderate neck pain. I can t drive my car as long as I want because of moderate pain in my neck. I can hardly drive at all because of severe pain in my neck. I can t drive my car at all. SECTION 9 SLEEPING I have no trouble sleeping. My sleep is slightly disturbed (less than one hour sleepless). My sleep is mildly disturbed (1-2 hours sleepless). My sleep is moderately disturbed (2-3 hours sleepless). My sleep is greatly disturbed (3-5 hours sleepless). My sleep is completely disturbed (5-7 hours sleepless). SECTION 10 RECREATION I am able to engage in all my recreation activities with no neck pain at all. I am able to engage in all my recreation activities, with some pain in my neck. I am able to engage in most, but not all of my usual recreation activities because of pain in my neck. I am able to engage in a few of my usual recreation activities because of pain in my neck. I hardly do any recreation activities because of pain in my neck. I can t do recreation activities at all.

Bellevue Chiropractic Group Disclosure & Consent Chiropractic Adjustments and Care TO THE PATIENT: You have a right as a patient to be informed about your condition and the recommended chiropractic adjustments and other chiropractic procedures to be used so that you may make the decision whether or not to undergo the procedure after knowing the potential risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure. I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including examination, various modes of physical therapy and diagnostic X-rays, on me (or the patient named below, for whom I am legally responsible) by the Doctor of Chiropractic at Bellevue Chiropractic Group and/or other licensed Doctors of Chiropractic or those working at the clinic or office who now or in the future treat me while employed by, working or associated with, or serving as a backup for the Doctor of Chiropractic at Bellevue Chiropractic Group. I understand that I will have the opportunity to discuss with the Doctor of Chiropractic named below, my diagnosis, the nature and purpose of chiropractic adjustments and other procedures and alternatives before treatment begins. I understand and I am informed that, in the practice of chiropractic there are some risks to exam and treatment including, but not limited to, fractures, disc injuries, strokes, dislocations, sprains and increased symptoms and pain or no improvement of symptoms or pain. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, and is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions, and all my questions have been answered fully and satisfactorily. By signing below, I consent to treatment by the Doctors of Chiropractic at Bellevue Chiropractic Group. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. To be completed by the patient: Print Name Signature of Patient Date Signed To be completed by the patient s representative, if necessary, e.g., if the patient is a minor or physically or legally incapacitated: Print Name of Patient Print Name of Patient s Representative Signature of Patient s Representative As: Relationship or Authority of Patient s Representative Date Signed To be completed by doctor of staff Witness to Patient s Signature Translated By To be completed by doctor or staff Date Date