Apply Here Apply For The Neuropathy Program Step 1 of 5 20% Please fill out the application entirely and legibly.We need all information for insurance purposesName(Required)NicknameAddress(Required)City(Required)State(Required)Zip(Required)Phone*We will need to contact you both by phone & email.Please be sure to give us the best phone number to reach you*Email Date of Birth(Required) MM slash DD slash YYYY Social Security Number*If you have Medicare, we need you to list your SSN above or provide us with the Medicare card*Spouse’s Name(Required)Spouse’s Phone NumberYour Occupation(Required)Retired? Yes No REVIEW OF SYMPTOMSPlease check all that apply Foot Pain Hand Pain Low Back Pain Neck Pain Foot Numbness Hand Numbness Diabetes High Cholesterol High Blood Pressure Pacemaker/Defibrillator Herniated Disc Bulging Disc Spinal Stenosis Degenerative Disc Vascular Problems Leg Pain Plantar Fasciitis Morton's Neuroma Cancer Chemotherapy Arthritis in Hands Arthritis in Feet Implanted Cord/Bladder Stimulator Sciatica Pinched Nerve Poor Circulation Joint Replacement Foot Surgery Poor Wound Healing Excessive thirst or urination PRESENT HEALTH CONDITIONIn order of importance, list the health problems you are most interested in getting corrected: Add RemoveList approximately how long you have noticed these problems: Add RemoveIs there a certain time of day any of these problems are better or worse?List the things you have used for these problems:GabapentinNeurotinLyricaCymbaltaPhysical TherapyPain medicationsAleveTylenolIbuprofenMotrinChiropracticMassage TherapyInfectionsCreamsList the things you have used for these problems: Add RemoveList the things you have used for these problems:Is your balance/walking ability affected? If yes, please describe:What do you think is causing your problem?Name of all doctors you have seen for these problems and treatment you received: Add Remove Have your symptoms: Improved Worsened Stayed the same List anything that makes your condition worse Add RemoveList anything that makes your condition better Add RemoveHow would you describe the symptoms? Please check ALL that apply Aching Pain Stabbing Pain Sharp pain Tiredness Numbness Tingling Pins & Needles Pain Heavy Feeling Hot Sensation Throbbing Pain Dead Feeling Cold Hands/Feet Cramping Swelling Burning Electric Shocks Is this condition interfering with any of the following? Sleep Work Daily Activities Recreational Activities Walking Standing SOCIAL HISTORYDo you smoke? Yes No If yes, how many cigarettes daily?Do you drink? Yes No If yes, how many drinks per week?Do you exercise regularly? Yes No If yes, please describe type & how often:CURRENT PAIN LEVELSHow would you rate your pain in the last week? 1 2 3 4 5 6 7 8 9 10 NO PAIN TO WORST PAIN POSSIBLEIf you had to accept some level of pain after completion of treatment, what would be an acceptable level? 1 2 3 4 5 6 7 8 9 10 NO PAIN TO WORST PAIN POSSIBLE PREVIOUS HEALTH HISTORYThis is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization, unless you sign here indicating that we can release copies by your verbal request.NameSignaturePlease give name, address, and office phone number of your primary care physician.NamePhoneAddressWhen were you last seen there?May we send them updates on your treatment/condition? Yes No List ALL allergies/sensitivities to medication, food, and other items here:Item you react to: Add RemoveReaction: Add RemoveList the prescription drugs you are currently taking ( or you may attach a list):Name Add RemoveDase (mg or JU) Add RemoveTimes Daily Add RemoveList all nutritional supplements (vitamins, herbs, homeopathies, etc.) as above:List Add Remove Plainfield Family Chiropractic Patient Quality Of Life SurveyName:Date MM slash DD slash YYYY Please take several minutes to answer these questions so we can help you get better.(Please circle as many that apply) 1. How have you taken care of your health in the past? a. Medications b. Emergency Room c. Routine Medical d. Exercise e. Nutrition/Diet f. Holistic Care g. Vitamins h. Chiropractic i. Other (please specify): Other (please specify):2. How did the previous method(s) work out for you? a. Bad results b. Some results c. Great results d. Nothing changed e. Did not get worse f. Did not work very long g. Still trying h.Confused 3. How have others been affected by your health condition? a. No one is affected b. Haven't noticed any problem c. They tell me to do something d. People avoid me 4. What are you afraid this might be ( or beginning) to affect ( or will affect)? a. Job b. Kids c. Future ability d. Marriage e. Self-esteem f. Sleep g. Time h. Finances i. Freedom 5. Are there health conditions you are afraid this might turn into? a. Family health problems b. Heart disease c. Cancer d. Diabetes e. Arthritis f. Fibromyalgia g. Depression h. Chronic Fatigue i. Need surgery How has your health condition affected your job, relationships, finances, family, or other activities? Please give examples:What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) Give 3 examples:What are you most concerned with regarding your problem?Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specificWhat would be different/better without this problem? Please be specificWhat do you desire most to get from working with us?What would that mean to you?
