New Patient Medical Intake Questionnaire
Full NameToday's DateDate of Birth
What do you prefer to be called?SS#:
Home Address:
City State Zip
Home #: Work #:
Work Address:
Fax #: E-Mail:
Occupation Company
Martial Status: Please markMS WD Number of children
How did you hear about our office?
Have you had chiropractic treatment in the past? YesNo
When? Doctor's Name:
What kind of results did you obtain? ExcellentGoodFairPoor
Health Information
A: What is your primary reason for consulting my office? What type of health problems are you seeking help for?
1:
Type of pain: Sharp Dull Aching Throbbing Burning Shooting Numbness Pounding
Tingling Cramping Stinging Other type of pain
2:
3:
4:
5:
B: Please describe in detail what may have caused your problem:
C: How long have you had this condition?
D: Have you had this same problem(s) in the past? Yes No
E: List other medical physicians you have seen for this condition(s):
1: 2:
3: 4:
F: What type of treatments have you had for your health problem(s)?
G: List medications you are presently taking:
1: 2: 3: 4:
5: 6: 7:
H: List any surgeries and give year:
I: What activities aggravate your conditions?
J: Is your condition getting worse? Yes No
K: Is this condition interfering with:work sleep recreation daily activities
other
L: How long has it been since you felt well?
M: Do you take supplements: Yes No
Please list your present supplements:
N: Give a description of your job duties:
O: What is the age of your mattress? Do you wear Orthotics Heel Lift
Arch Supports
P: Date of last physical: Date of last blood test:
Q: Who is your family doctor?
R: What is your blood type: O A B AB Are you pregnant? Yes No
S: Is your mother still living? Yes No Is your father still living? Yes No
If yes do they have any health problems? Yes No Please list:
T: If your parents are deceased, what was the cause of death and at what age:
Please check if you are suffering or have suffered from any of the following health conditions
History of any of the following conditions:
Cancer Heart Attack Stroke Diabetes Liver Disease Chronic Fatigue Fibromyalgia
General Health Review
Overweight Underweight Rarely Exercise Drink less than 8 glasses of water per day
Sleep less than 7 hours/night Insomnia
Head, Ear, Eye System Review
Headaches Migraines Ringing in your ears Frequent ear infections Meniere's Acoustic Neuroma
Cardiovascular System Review
High triglycerides High blood pressure Circulation problems High cholesterol
Blood clots Varicose veins Cold hands & feet Swollen ankles Palpitations Leg cramps
Frequent nosebleeds Arrhythmia Dizziness
Respiratory System Review
Allergies Sinusitis Asthma Post-nasal drip Pneumonia Emphysema Bronchitis
Gastrointestinal/Digestive System Review
Acid reflux Digestion problems Gallbladder problems Irritable bowel Indigestion Excessive hunger
Constipation Diarrhea Frequently nauseated Drowsy after eating Abdominal gas Had parasites
Bloody stools/Fissures Abdominal pain Hemorrhoids Ulcers Use laxatives Gall bladder disease
Frequently vomit
Urinary/Kidney System Review
Frequent urination History of kidney stones Kidney infections
Dermatological/Skin System Review
Eczema Hives Psoriasis Rosasea Acne Suspicious mole Itching Skin Melanoma
Neurological System Review
Multiple sclerosis Senility Parkinson's Alzheimer's Disease Lou Gehrig's Disease Epilepsy
Brain Tumor Other
Neuromuscular/Joint System Review
TMJ Rotator cuff Tennis elbow Rib pain Knee pain Herniated disc Ankle sprains Heel Spurs
Foot pain Scoliosis Post-surgical pain Osteoarthritis Carpal tunnel Rheumatoid Arthritis
Endocrine System Review
Anemia Fatigue Hypoglycemia Dizziness Motion sickness Chronic Fatigue Excessive thirst
Excessive perspiration Osteoporosis Thyroid problems Hair Loss Lupus
Mouth, Nose and Throat System Review
Difficulty swallowing Toothaches Frequent sore throats Frequent canker sore
Frequent fever blisters Gums bleed Frequent colds Frequent nose bleeds Sensitive to chemicals
Addictions
Alcohol addiction Smoking addiction Drug Addiction
Emotional/Psychological System Review
Do you often cry Frequently miserable and sad Easily angered Wish you were dead and away from it all
Lot of stress ADHD Autism
For Women Only
Painful Periods Dysmenorrhea Menstrual cramps Had partial hysterectomy
Had complete hysterectomy Yeast infections Fibroid tumors/cysts Take birth control pills Hot Flashes
Infertility PMS Menopause Symptoms
For Men Only
Impotence Prostate problems
Other Conditions:
General Pain Disability Questionnaire
Please Read: The following questionnaire is designed to enable us to understand how much your pain has affected your ability to manage your everyday activities. Please answer each section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CHECK THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.
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 worst possible pain
Section 2---- Personal Care (Washing, Dressing, etc.)
I can look after myself normally without causing extra pain1
Mild pain; no restrictions
Moderate pain; need to go slowly
Moderate pain; need some assistance
Severe pain; need 100% assistance
Section 3 ---- Lifting
I can lift heavy weights, without extra pain
Increased pain with heavy weight
Increased pain with moderate weight
Increased pain with light weight
Increased pain with any weight
Section 4:--- Walking
Pain does not prevent me from walking any distance
Pain prevents me from walking more than one mile
Pain prevents me from walking more than 1/2 mile.
Pain prevents me from walking more than 1/4 mile
Increased pain with all walking
Section 5---Work
Can do usual work plus unlimited extra work
Can do usual work; no extra work
Can do 50% of usual work
Can do 25% of usual work
Cannot work
Section 6---Standing
No pain after several hours
Increased pain after several hours
Increased pain after 1 hour
Increased pain after 1/2 hour
Increased pain with any standing
Section 7---Sleeping
Perfect sleep
Mildly disturbed sleep
Moderately disturbed sleep
Greatly disturbed sleep
Totally disturbed sleep
Section 8---Recreation
Can do all activities
Can do most activities
Can do some activities
Can do few activities
Cannot do any activities
Section 9---Traveling
I get no pain on long trips
Mild pain on long trips
Moderate pain on long trips
Moderate pain on short trips
Severe pain on long trips
Section 10---Frequency of Pain
No pain
Occasional pain; 25% of the day
Intermittent pain; 50% of the day
Frequent pain; 75% of the day
Constant pain; 100% of the day
Financial Information
Let's clarify the financial aspects of your care so we can direct our attention to helping you get well. If you have health insurance, an HMO, depend on Medicare, were injured on the job, in an auto accident or some other personal injury, you may have other options.
First Visit: On your first visit you'll meet either Dr. Grisanti or Dr. Carrano to discuss your current health situation and to see if you're a good candidate for Functional Medical/Chiropractic care. If the doctor accepts you as a patient, he will conduct a thorough examination. This will help him identify the likely cause(s) of your problem. Associated fees include:
First Visit Consultation and Exam - $85.00 - $200.00
Physical Examination with report - $165.00
Nutritional & Functional Medicine Consultation - $100.00-$200.00
Progress Nutritional & Functional Medicine Consultations - $50.00
Comprehensive blood profile - $150.00 - $500.00
Functional Medicine Lab Tests: Prices Vary
Services Available: MRI, CT, Bone Scan, Mammography, Echocardiography, EKG/Stress EKG, Ultrasound, Arthrography, Fluoroscopy, Bone Density - Prices Vary
Necessary X-ray views of the spine or related areas - $25.00-$150.00
Spinal adjustment (s) - $40.00 - $55.00
Physiologic Therapeutics - $25.00
Natural Medicine Prescription & Clinical Recommendations - Prices Vary
Second Visit: At your Case Review the doctor will tell you what he found, what he can do to help, how long it may take and estimate how much it will cost. The doctor will also review other courses of action and offer you choices. Our customary fees for this visit include:
Case Review - $50.00
Spinal adjustments - $40.00 - $55.00
Physiologic Therapeutics - $25.00 (ultrasound, interferential therapy, cervical/lumbar decompression)
Laser Therapy - $40.00
Trigger Point Therapy - $25.00
Rehabilitation exercises - $35.00
Electrical Acupuncture/Meridian Therapy - $50.00
Orthotic Fitting $200-$350
Regular Visit: Your chiropractic care may consist of a series of specific adjustments to add motion to spinal segments and/or other joints that are not moving correctly, soft-tissue treatments to improve muscle and ligament function and state of art rehabilitation exercises to strengthen the weakened areas. Retraining the spine and/or joints takes time. Each visit builds on the ones before. Some patients see rapid progress and others find their recovery slower.
Your natural medicine care will be a series of personal consultations with the doctor and will be scheduled at 15, 30 and 45-minute time slots.
See above under Second Visit for customary fees
Progress Examination: Dr. Grisanti and/or Dr. Carrano will monitor your progress with periodic exams every 6 visits. These findings help document your recovery. He may modify your visits based on these results.
Progress Examination - $50.00
Progress Report - $25.00
Post-X-rays - $15.00 - $60.00
Third Parties: The patient receiving our care pays our fees. I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that amount authorized to be paid directly to Dr. Grisanti and/or Dr. Carrano will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my treatment, any fees for services rendered me will be immediately due and payable.
Credit Limit: We will extend a credit limit of $150.00
Insurance Information
Do you prefer to pay by: Cash Check Visa MasterCard Discover American Express
Do you have health insurance? Yes No If yes:
Name of company:
Name of employer of the insured:
Address:
Telephone number for verification of benefits (see insurance card): ID #:
Group #: Name of insured:
Your relationship to insured: Self Spouse Child Other
Date of birth of the insured:
Individual Consideration Contract: If there is a financial hardship associated with receiving care in our office, please call our office and speak to our office manager for available options: Call 864-292-0226
Billing: Outstanding balances will be billed monthly and considered past due 10 days after the invoice date. We will pass along the fee of $20.00 our bank charges us for any returned checks. Balances beyond 30 days will be assessed interest at an APR of 18% plus any legal or collection fees.
Our Promise: We only accept patients we believe we can help. If we determine you have a health problem we can not help we will tell you and refer to a physician who can best help you.
Thank you for taking the time to complete this questionnaire