Kish Chiropractic 320 West Main Street Mount Horeb, WI 53572 | 608.437.3600
History of Primary Complaint If you are filling this form in electronically, you can use the tab key to move through the fields.
Address: / City: / State: / Zip:
Home Phone: / Work Phone: / Cell Phone:
Email: / SSN (Include if you have Medicare/Medicaid):
Birth Date: / Age: / Height: / Weight:
Who referred you? How did you choose us?
Race: White Black/African American Hispanic Other Choose not to specify
Multi- Racial: Yes No Choose not to specify
Ethnicity: Hispanic or Latino Not Hispanic or Latino Choose not to specify
Preferred Language: English Spanish Other Choose not to specify
Health History
Have you been treated by a physician within the last year? Yes - No
If so, what were you treated for?
Are you currently taking prescribed medications? Yes - No If so, which medications? (include dosage and frequency)
Do you currently smoke tobacco of any kind? Yes Former smoker Never been a smoker
What medications are you allergic to?
None or List here:
Do you have any implants (plates, wires, screws) or artificial joint, nerve stimulator, or pace maker?
None or List here:
For women: Is there a possibility that you may be pregnant? Yes - No
List any surgeries below / Date / List any accidents below / Date
1. / 1.
2. / 2.
3. / 3.
Primary Complaint
Date of onset: / How did your injury occur?
This problem prevents me from:
Location of injury
Pain now
0 1 2 3 4 5 6 7 8 9 10
Circle two: pain best & worst
0 1 2 3 4 5 6 7 8 9 10 / Chief complaint
Neck pain
Shoulder pain
Mid back pain
Low back pain
Leg pain ( L / R )
Headache
Hip or Buttock
Other: / Mode of onset
Overexertion or
strenuous position
Auto accident
Fall / trip / slip
Work related
Gradual
Other: / Character of discomfort
Dull ache
Burning
Sharp/stabbing
Throbbing
Radiating
Numbness/tingling
Other:
Severity
Mild annoyance, no impairment
Slight – some mild impairment
Moderate – marked impairment
Severe – incapacitated or bedridden / Duration
Intermittent (< 25% of the time)
Occasional (25%-50% of the time)
Frequent (50%-75% of the time)
Constant (75%-100% of the time)
Other:
Relation to other body systems
Bowel/bladder
Muscle Weakness
Numbness/tingling
Fever in last week
Night sweats
No apparent relationship
Other: / Aggravating factors
Cough/sneeze/bowel movement
Lifting/bending/push/pull
Driving/riding/sitting
Walking/running/standing
Change body positions
Other: / Relieving factors
Rest
Hot packs
Cold packs
Bracing/taping
Sitting/standing/lying
Stretching / exercise
Other:
Were you treated?
Yes - No / Who have you seen? / Did you have:
Xrays CT Scan MRI
Are you taking <PAIN> medication for this condition? Yes - No
If so, what kind of medication?
Anything else you want to share about your condition?
Secondary Complaint
Date of onset: / How did your injury occur?
This problem prevents me from:
Location of injury
Pain now
0 1 2 3 4 5 6 7 8 9 10
Circle two: pain best & worst
0 1 2 3 4 5 6 7 8 9 10 / Chief complaint
Neck pain
Shoulder pain
Mid back pain
Low back pain
Leg pain ( L / R )
Headache
Hip or Buttock
Other: / Mode of onset
Overexertion or
strenuous position
Auto accident
Fall / trip / slip
Work related
Gradual
Other: / Character of discomfort
Dull ache
Burning
Sharp/stabbing
Throbbing
Radiating
Numbness/tingling
Other:
Severity
Mild annoyance, no impairment
Slight – some mild impairment
Moderate – marked impairment
Severe – incapacitated orbedridden / Duration
Intermittent (< 25% of the time)
Occasional (25%-50% of the time)
Frequent (50%-75% of the time)
Constant (75%-100% of the time)
Other:
Relation to other body systems
Bowel/bladder
Muscle Weakness
Numbness/tingling
Fever in last week
Night sweats
No apparent relationship
Other: / Aggravating factors
Cough/sneeze/bowel movement
Lifting/bending/push/pull
Driving/riding/sitting
Walking/running/standing
Change body positions
Other: / Relieving factors
Rest
Hot packs
Cold packs
Bracing/taping
Sitting/standing/lying
Stretching / exercise
Other:
Were you treated?
Yes - No / Who have you seen? / Did you have:
Xrays CT Scan MRI
Are you taking <PAIN> medication for this condition? Yes - No
If so, what kind of medication?
Anything else you want to share about your condition?
Do you currently have or have you previously had any of the following: (check S for Self, M for Mother, and F for Father)
Alcoholism / S M F
| | / Diabetes / S M F
| | / Muscular dystrophy / S M F
| |
Anemia / S M F
| | / Disability / S M F
| | / Neck pain / S M F
| |
Arthritis / S M F
| | / Indigestion/ heart burn / S M F
| | / Nervousness or anxiety / S M F
| |
Asthma / S M F
| | / Dislocated joint / S M F
| | / Numbness / S M F
| |
Back pain / S M F
| | / German measles / S M F
| | / Polio / S M F
| |
Bladder trouble / S M F
| | / Headaches / S M F
| | / Poor circulation / S M F
| |
Bone fracture / S M F
| | / Heart trouble/ disease / S M F
| | / Psychiatric hospitalization / S M F
| |
Cancer / S M F
| | / Hepatitis A/B/C / S M F
| | / Rhumatic fever / S M F
| |
Chest pain / S M F
| | / High blood pressure / S M F
| | / Shoulder pain / S M F
| |
Constipation / S M F
| | / Kidney disorder / S M F
| | / Sinus problems / S M F
| |
Concussion / S M F
| | / Loss of bowel control / S M F
| | / Substance abuse/ addiction / S M F
| |
Convulsion/ Seizures / S M F
| | / Menstrual cramps / S M F
| | / Tuberculosis / S M F
| |
Depression / S M F
| | / Multiple sclerosis / S M F
| | / HIV / S M F
| |
Has a doctor diagnosed you with hypertension recently? Yes - No / Describe:
Has any doctor diagnosed you with Diabetes presently? Yes - No / What kind? Type 1 Type 2
Are there any other health concerns you would like to share?
Please fill in the information for your immediate family members
Family Member / Year Born / Age at death / Cause of death / All health conditions
Mother
Father
Brother
Brother
Sister
Sister
Other
Other
Acknowledgements (Please check each box)
Chiropractic Care / I Instruct the chiropractor to deliver the care that, in his professional judgment, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct art form medicine and does not proclaim to cure any named disease or entity.
Privacy verification / I may request a copy of the Privacy Policy and understand that it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties. I grant permission to be contacted as stated in the next section.
Permission to contact / I grant permission to be contacted to confirm or reschedule an appointment via phone, text or email and to be sent occasional cards, letters, emails or health information as an extension of my care in this office.
Payment verification / I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive. Payment is due at the time of service. Billing for any service not paid within 60 days will incur a rebilling fee of $5.00 and interest at 12% APR.
X-ray verification / I realize an X-ray examination may be hazardous to an unborn child and I certify that to the best of my knowledge I am not pregnant and I understand the risks. Date of last menstrual period:
General verification / To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.
Please choose ONEsecurity question and give an answer so we can set up your account:
What is the name of your favorite pet?
In what city were you born?
On what street did you grow up?
What is your mother’s maiden name?
What was the make of your first car?
What is your favorite movie? / Please print the answer below, legibly:
(must be at least 6 characters)
Is there anything else you would like for us to know?
PRINT NAME:
OR PARENT/ GUARDIAN:
SIGNATURE:
DATE:
1
Print Patient Name ______