Prairielands Chiropractic Clinic - Chiropractor In Council Bluffs, IA USA

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General Information

First Name *

Middle Name

Last Name *

Street Address *

City *

State *

Zip Code *

Home Phone *

Work Phone

Cell Phone

Email (Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.) *

Referred By *

Birth Month *

Birth Day *

Birth Year *

Patients Gender *

MaleFemale

Insureds Name

Same as Patient or

First Name

Middle Name

Last Name

Street Address

City

State

Home Phone

Work Phone

Cell Phone

Birth Month

Birth Day

Birth Year

Gender

MaleFemale

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone Number *

Insurance

Patients Relationship to Insured

SelfSpouseChildOther (Please Describe)

Other

Patient Status

SingleMarriedOther (Please Describe)EmployedFull-Time StudentPart-Time Student

Other

If Married, Anniversary Date

Is Patients Condition Related to:

Employment? (Current or Previous)Auto Accident (Name State Below)Other Accident (Please Describe)

Auto Accident State

Other Accident

Type of Issurance

MedicareMedicaidChampusChampvaGroup Health PlanOther (Please Describe)

Other

Primary Insurance Information

Is there another Health Benefit Plan?

YesNo

ID Number

Policy, Group, or FECA number

Employers Name or School Name

Insurance Plan Name or Program Type

What Are Your Wellness Goals?

What are your wellness goals? Choose from the following or specify others.

Stress ReliefPain ReliefBetter BreathingFlexibilityIncreased StrengthWeigh ManagementImproved CirculationCardiovascular ConditioningBetter Body AlignmentFocus on the PresentOther

Other Wellness Goals

What are your wellness interests? We can email you Newsletters from the following topics.

Doctors AnnouncementsStress ManagementChildrens Health IssuesWomens Health IssuesExercise

Have you lost the ability to do something you would like to regain?

YesNo

If yes, please list or explain

What challenges do you have or want to overcome?

Are there certain motions or postures you need to avoid of that are painful or uncomfortable?

Yes No

If yes, please list or explain

Patient Intake Form

Is todays problem caused by *

Auto AccidentWorkmans CompensationOther

What part of the body are you experiencing pain or symptoms? Check all that apply. *

HeadachesNeckUpper BackMid BackLow BackShoulderElbows/Upper ArmWristHandHipUpper LegKneeLower LegAnkle/FootJaw

How often do you experience your symptoms?

Constantly (76-100% of the time)Frequently (51-75% of the time)Occasionally (26-50% of the time)Intermittently (1-25% of the time)

How would you describe the type of pain?

Sharp NumbDullTinglyDiffuseSharp with MotionAchyShooting with MotionBurningStabbing with MotionShootingElectric like with MotionStiffOther

If other, please describe

How are your symptoms changing with time?

Getting WorseStaying the SameGetting Better

Using a scale from 1 to 10 (10 being the worst), how would you rate your problem?

How much has the problem interfered with your work?

Not at allA little bitModeratelyQuite a bitExtremely

How much has your problem interfered with your social activities?

Not at allA little bitModeratelyQuite a bitExtremely

Who else have you seen for your problem?

No One ChiropractorER PhysicianMassage TherapistNeurologistOrthopedistPhysical TherapistPrimary Care PhysicianOther

Have you had recent

X-RaysMRICT ScanLab WorkOther

Date taken

Location

How long have you had this problem?

How do you think your problem began?

Do you consider this problem to be severe?

YesYes, at timesNo

What aggravates your problem?

What helps your problem?

What concerns you most about your problem? What does it prevent you from doing?

Height

Weight

Occupation

How would you rate your overall health?

ExcellentVery GoodGoodFairPoor

What type of exercise do you do?

StrenuousModerateLightNone

Health History

Indicate if you have any immediate family members with the following

Rheumatoid ArthritisDiabetesLupusHeart ProblemCancerALSOther

If other, please explain

For each of the conditions listed below, place a check in the PAST box if you have had the condition in the past. If you presently have a condition listed below, place a check in the CURRENT box. If both apply, check both.

Headaches

Past Current

Neck Pain

Past Current

Upper Back Pain

Past Current

Mid Back Pain

Past Current

Low Back Pain

Past Current

Shoulder Pain

Past Current

Elbow/Upper Arm Pain

Past Current

Wrist Pain

Past Current

Hand Pain

Past Current

Hip Pain

Past Current

Upper Leg Pain

Past Current

Knee Pain

Past Current

Ankle/Foot Pain

Past Current

Jaw Pain

Past Current

Joint Pain/Stiffness

Past Current

Arthritis

Past Current

Rheumatoid Artritis

Past Current

Cancer

Past Current

Tumor, Cysts. Lipomas

Past Current

Asthma

Past Current

Chronic Sinusitis

Past Current

High Blood Pressure

Past Current

Heart Attack

Past Current

Chest Pains

Past Current

Stroke

PastCurrent

Angina

PastCurrent

Kidney Stones

PastCurrent

Kidney Disorder

PastCurrent

Bladder Infection

PastCurrent

Painful Urination

PastCurrent

Loss of Bladder Control

PastCurrent

Prostate Problems

PastCurrent

Abnormal Weight Gain/Loss

PastCurrent

Loss of Appetite

PastCurrent

Abdominal Pain

PastCurrent

Ulcer

PastCurrent

Hepatitis

PastCurrent

Liver/Gallbladder Disorder

PastCurrent

General Fatigue

PastCurrent

Muscular Incoordination

PastCurrent

Visual Disturbances

PastCurrent

Dizziness

PastCurrent

Diabetes

PastCurrent

Excesive Thirst

PastCurrent

Frequent Urination

PastCurrent

Smoking/Tobacco Use

PastCurrent

Allergies

PastCurrent

Depression

PastCurrent

Systemic Lupus

PastCurrent

Epilepsy

PastCurrent

Dermatitis/Eczema/Rash

PastCurrent

HIV/AIDS

PastCurrent

For females only

Hormonal Birth Control

PastCurrent

Hormonal Replacement

PastCurrent

Pregnancy

PastCurrent

List all prescription medications you are currently taking and for what condition. *

List all of the over-the-counter medications, supplements, and/or herbs you are currently taking and why. *

List all surgical procedures you have had and when they occured. *

What activities do you do outside of work? What are your hobbies?

Have you ever been hospitalized?

Yes No

If yes, why and when?

Have you had significant past trauma (fractures, falls, motor vehicle accidents, etc.)?

YesNo

If yes, please explain.

Is there anything else that is pertinent to the visit today?

Have you ever been seen by a chiropractor before?

YesNo

If yes, how was your experience?

ExcellentGoodFairPoor

Are you under the care of another physician/provider for any of the above of other conditions?

YesNo

If yes, please list physicians name and facility.

Patient Online Signiture

Name

The above information is true and filled out to the best of my knowledge.

I agreeI disagree

Enter the verification code in the box below.

Verification Code: *

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Office Hours

Mon	8 - 12	12 - 7
Tue	8 - 12	12 - 7
Wed	8 - 12	12 - 7
Thu	8 - 12	12 - 7
Fri	8 - 12	12 - 7
Sat	8 - 2	Closed
Sun	Closed	Closed

Call Us:
(712) 256-2561

General Information

Insureds Name

Emergency Contact

Insurance

Primary Insurance Information

What Are Your Wellness Goals?

Patient Intake Form

Health History

Patient Online Signiture

Newsletter Sign Up

Member Login

Office Hours

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