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Reactivation Update

Reactivation Update

Welcome Back!

Advanced Chiropractic & Wellness Re-activation Form

First Name*

Last Name*

Today's Date

Address

City

State/Province

Zip

Email*

Insurance Provider

Insurance ID:

1. What brings you into the office today?

2. When was the first occurrence of this?

3. Is it accident related?

Yes

No

If yes, please describe:

4. If not, accident related, how did it occur?

5. Have you had this problem before?

Yes

No

If yes, when?

6. Do you have pain or tightness?

Yes

No

If yes, where?

7. On a scale of 1-10 with 10 being the worst, how would you rate the current problem?

8. The pain is (check all that apply):

Dull

Aching

Numb

Superficial Pain

Deep Pain

Burning

Tingling

Shooting

Tight/Stiff

Pain worse in am

Pain worse in pm

Pain is worse with cold

Pain is better with cold

Pain is worse with heat

Pain is better with heat

Pain is worse with pressure

Pain is better with pressure

9. I have (check all that apply)

Swollen joints

Arthritis/joint pain

Tendonitis

Bone pain

Muscle cramping

Muscle pain

Repetitive strain injury

Other

Other:

10. All updated medications, vitamins, minerals, or supplements:

Please mark all areas of pain on diagram below (A=aching B=Burning N=numbness P=pins and needles S=Stabbing pain O=other type of sensation)

Please mark all areas of pain on diagram below (A=aching B=Burning N=numbness P=pins and needles S=Stabbing pain O=other type of sensation)

Thank you for taking the time to fill out this form.

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Saturday:

8:00 am - 2:00 pm

Sunday:

Closed

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