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How would describe your chief complaint at this time?
When did it start? Date_______________________________________________________________________
(include at least the moth and year, day if known)
What is your history with this injury? [ ] Sudden Trauma [ ] Reoccurrence [ ] Repetitive Trauma
What makes the pain worse?_______________________________________________________________________
What make the pain better? _______________________________________________________________________
Where is the pain located?_________________________________________________________________________
At what time of day or week is the pain worse?_______________________________________________________
The pain is…….
[ ] Intermittent [ ] Constant
It usually last for [ _____] minute(s) [ ____] hours [ ____] day(s) [____] week(s)
Disabled from __________________________________________ to _______________________________________
I authorize Kenneth A. Felt, DC to release any information necessary to expedite insurance claims on my behalf.
I understand that I am responsible for charges that are not covered by my insurance plan.
RELEASE OF INFORMATION: I authorize the physician examining and / or treating me to release to any third
party any Medical information and records concerning diagnosis and treatment when requested.
Signature of Patient or Guardian ___________________________________________ Date: ___________________