Intake Form New patients at Montesano Chiropractic may fill out our online form prior to their appointment - thank you! Please enable JavaScript in your browser to complete this form. - Step 1 of 5Personal InformationToday's Date *Date of Birth *Patient's Age *Name *Gender: *MaleFemaleRace *American Indian or Alaska NativeAsianBlack/African AmericanNative Hawaiian or Pacific IslanderCaucasian/WhiteHispanic or LatinoOtherOther Race: *Email *Home PhoneMobile Phone *Would you like to receive text message reminders for appts? *YesNoAddress *Address Line 1Address Line 2CityWashingtonAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextEmployer InformationEmployment Status *EmployedUnemployedRetiredEmployer Name *Employer Address *Address Line 1Address Line 2CityWashingtonAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs this visit from an auto accident or L&I Claim *YesNoNextInsurance InformaitonPrimary Insurance *Member ID *Group ID *Secondary InsuranceSecondary Insurance Member IDSecondary Insurance Group IDNextPatient Medical InformationPlease print this drawing and indicate where you have pain/symptoms and bring with you to your appointment.How ofter to you experiance your symptoms? *Constantly (76-100% of the time)Frequently (51-75% of the time)Occasionally (26-50% of the time)Intermittantly (1-25% of the time)How would you describe the type of pain? *SharpDullDiffuseAchyBurningShootingStiffNumbTinglySharp with motionShooting with motionStabbing with motionElectric like with motionOtherPlease explain *How are your symptoms changing with time? *Getting WorseStaying the SameGetting BetterHow would you rate your problem using a scale of 0-10 (10 being the worst) Selected Value: 0 How much has this interfered with work? *Not at allA little bitModeratelyQuite a bitExtremelyHow much has this interfered with social activities? *Not at allA little bitModeratelyQuite a bitExtremelyWho else have you seen for your problem (Check all that apply) *ChiropractorER PhysicianMassage TherapistNeurologistOrthopedistPhysical TherapistPrimary Care PhysicianNo oneOtherPlease indicate who else you have seen for your problem *How long have your had this problem? *How do you think your problem began? *Do you consider this problem to be severe? *YesYes, at timesNoWhat aggravates your problem? *What concerns you most about your problem - what does it prevent you from doing? *What is your:Height *Weight? *Occupation? *How would you rate your overall health? *ExcellentVery GoodGoodFairPoorWhat type of exercise do you do? *StrenuousModerateLightNoneNextMedical HistoryIndicate if any immediate family members have the following condition(s): *Rheumatoid ArthritisHearth ProblemsDiabetesCancerLupusALSNone of the abovePresent Conditions *HeadachesNeck PainUpper Back PainMid Back PainLow Back PainShoulder PainElbow/Upper Arm PainWrist PainHand PainHip PainUpper Leg PainKnee PainAnkle/Foot PainJaw PainJoint Pain/StiffnessArthritisRheumatoid ArthritisCancerTumorChronic SinusitisHigh Blood PressureHeart AttackChest PainsStrokeAnginaKidney StonesKidney DisordersBladder InfectionPainful UrinationLoss of Bladder ControlAbnormal Weight Gain/LossLoss of AppetiteAbdominal PainUlcerHepatitisLiver/Gall Bladder DisorderGeneral FatigueMuscular IncoordinationVisual DisturbancesDizzinessDiabetesExcessive ThirstFrequent UrinationSmoking/Tobacco UseDrug/Alcohol DependenceAllergiesDepressionSystemic LupusEpilepsyDermatitis/Eczema/RashHIV/AIDSMen only: Prostate ProblemsWomen Only: Birth Control PillsWomen Only: Hormonal ReplacementWomen Only: PregnancyPast Conditions *HeadachesNeck PainUpper Back PainMid Back PainLow Back PainShoulder PainElbow/Upper Arm PainWrist PainHand PainHip PainUpper Leg PainKnee PainAnkle/Foot PainJaw PainJoint Pain/StiffnessArthritisRheumatoid ArthritisCancerTumorChronic SinusitisHigh Blood PressureHeart AttackChest PainsStrokeAnginaKidney StonesKidney DisordersBladder InfectionPainful UrinationLoss of Bladder ControlAbnormal Weight Gain/LossLoss of AppetiteAbdominal PainUlcerHepatitisLiver/Gall Bladder DisorderGeneral FatigueMuscular IncoordinationVisual DisturbancesDizzinessDiabetesExcessive ThirstFrequent UrinationSmoking/Tobacco UseDrug/Alcohol DependenceAllergiesDepressionSystemic LupusEpilepsyDermatitis/Eczema/RashHIV/AIDSMen only: Prostate ProblemsWomen Only: Birth Control PillsWomen Only: Hormonal ReplacementWomen Only: PregnancyList all the prescription medications you are currently taking: *List all the over-the-counter medications you are currently taking: *List all the surgical procedures you have had: *What activities do you do?Sit: *Most of the dayHalf the dayA little of the dayStand: *Most of the dayHalf the dayA little of the dayComputer work: *Most of the dayHalf the dayA little of the dayOn the phone: *Most of the dayHalf the dayA little of the dayWhat activities do you do outside of work?Have you ever been hospitalized? *NoYesIf yes, why? (copy)Have you had significant past trauma? *NoYesIf yes, why?Anything else pertinent to your visit?Patient Signature * Clear Signature Submit