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Personal Info
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Emergency Contact
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Contact
Do you consent to recieve Text Message/SMS and E-mail for appointment reminders and correspondences?
Yes
No
Medications
Medication
Add Another Medication
Other
We do not accept Personal Injury (PI) or Worker's Compensation (WC) claims. Is your injury the result of either?
No
Yes (i.e. civil law suits for motor vehicle accident and seeking damages from another party, hurt at work seeking WC for payment etc)
Primary Complaint
Primary Complaint
Wellness
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Neck
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Upper/Mid Back
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Low Back
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Hip(s)
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Shoulder
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Elbow
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Wrist/Hand
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Knee
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Ankle/Foot
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Other
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Location
Centrally Located
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Right-Sided
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Left-Sided
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Both Sides into Hips
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Both Sides into Shoulders
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Between Shoulder Blades
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Headache:
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Forehead
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Right-Sided
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Left-Sided
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Both Sides
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Behind Eyes
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Back of Head
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Other
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Level of Discomfort (0=no pain, 10=worst pain imaginable)
Verbal Pain Scale
0
1
2
3
4
5
6
7
8
9
10
No Pain
Worse Pain Imaginable
Describe Your Pain, Select all that Apply
No Pain
Deep/Dull
Sharp
Burning
Aching
Electric
Throbbing
Hot/Tingling
Stiff/Sore
Other
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Does your pain radiate?
No radiation
To right leg
To left leg
To right foot/toes
To left foot/toes
To right arm
To left arm
To right fingers/hand
To left fingers/hand
Other
Duration
Intermittent
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Occasional
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Constant
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When did your pain being?
A few days ago
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A few weeks ago
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A few months ago
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Always have had some pain/stiffness
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Specific Event (please describe)
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Have you had this pain before?
Yes
No
Any previous treatment? If so, please select all that apply.
Yes
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No
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Chiropractic
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Physical Therapy
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Massage Therapy
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Acupuncture
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Medications
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Surgery
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Other
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Aggravating Factors
Flexion
Extension
Rotation right
Rotation left
Laying on back
coughing/sneezing
Laying on side
Movement
Other
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Alleviating Factors
Cold/Ice
Heat
Adjustments
Massage
Stretching
Exercise
Rest
Lying on side
Lying on back
Medications
Other
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How well do you function with your pain?
100%
75%
50%
25%
I cannot function
Any Additional Complaints? (if applicable, please describe)
No Additional Complaints
Wellness
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Poor Posture
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Headaches
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Neck
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Upper/Mid Back
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Low Back
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Hip(s)
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Knee/Leg
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Ankle/Foot
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Shoulder
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Elbow/Arm
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Wrist/Hand
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Other
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Additional Information
Current Health History
What do you believe is wrong with you?
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Please list any heath care professionals you have seen in the past?
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Have you ever had Chiropractic Treatment before?
Yes
No
If yes how long has it been since your last treatment?
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How would you rate your overall posture?
0
1
2
3
4
5
6
7
8
9
10
Terrible
Perfect
Do you wear Orthotics?:
Yes
No
If yes, how old are your orthotics?
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Do you smoke?:
Yes
No
If yes, how many cigarettes do you smoke per day?
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Do you drink alcohol?
Yes
No
If yes, how many drinks do you have per week?
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Do you Exercise?
Yes
No
If yes, how many hours do your exercise per week?
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What is your weight?
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What is your height?
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Females Only, if you are pregnant, how many weeks are you pregnant?
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Goals of Care
Pain management/reduction
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Improve overall health & wellness
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Injury prevention
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Improve posture & mobility
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Improve strength & endurance
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Improve range of motion & flexibility
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Improve activities of daily living
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Improve diet & nutrition
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Other
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Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
Medical History
Head & Neck
Headaches
Neck Pain
Sinusitis
Hearing Problems
Ringing in the Ears
Vertigo/Dizziness
Eye Problems
Vision Problems
Nose Problems
TMJ (jaw pain)
Sore Throat
Voice Changes
Chest, Lung, Heart & Skin
Chest Pain
Stroke
Coronary Artery Disease
COVID-19
Palpitations
Blood Pressure Issues
Asthma
Allergies
Insomnia
Night Sweats
Lung Problems
Shortness of Breath
Skin problems
Bruise Easily
Internal, Digestive & Miscellaneous
Overweight
Cancer
Auto-Immune Disorder
Nausea
Heartburn
Poor Appetite
Loss of taste
Bloating
Numbness
Fainting
Anxiety
Depression
Belching/Gas
Diarrhea
Constipation
Abdominal Pain
Liver Problems â–¡
Kidney Problems
Frequent Urination
Urinary Tract Infections
Painful Urination
Prostate Trouble
Incontinence
Hemmorhoids
Muscle Cramps
Diabetes
Nosebleeds
Stiff Joints and muscles
Low Energy
Poor Appetite
Scoliosis
Poor Posture
Gynecological (Females Only)
Congested Breasts
Lumps in Breasts
Cramps or Backache
Irregular Cycle
Excessive Menstrual Flow
Endometriosis
Hot Flashes
Menopausal Symptoms
Irregular Periods
Painful Periods
Absent Periods
Family Health History
Cancer
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Stroke
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Heart Disease
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Hypertension
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Bleeding tendency
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Diabetes
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Alcoholism
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Arthritis
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Other
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Is there anything else you would like Dr. Quast to know?
Nope, All Set
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Yes:
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Are you open to Acupuncture as part of your treatment?
Yes
No
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