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Complaint #______________________________________________________________________________________


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)    

How long have you been having pain? 


  [  ] 1 week or less 


  [  ] 1-6 weeks   


  [  ] >6 weeks but less than 3months
  

  [  ] 3 month to 1 year


  [  ] Over 1 year   


How many times have you had this problem?  


  [  ] Never


  [  ] 1-3 episodes


  [  ] 4 or more episodes

When did you first have these or similar   
 
[  ] Never

   

[  ] Less than 6 months ago


[  ] 6 months to 1 year
 
[  ] More than 1 year ago

Yes Motor Vehicle Accident

[  ] Is your pain the result of a
      motor vehicle accident?

Yes Job Injury

[  ] Is your pain the result
     of a work related injury?

Yes Personal Injury

[  ] Is your pain the result of a personal

      injury outside of work or a motor

      Vehicle accident?

     Location of impact
  [  ] Rear end

  [  ] Frontal
  [  ] Side
  [  ] Both Front & Rear
  [  ] Both Side and Rear   

Have you been disabled from working

because of the pain during the year?........................[  ] Yes     [  ] No
 

Have you filed a workman's compensation claim?.........[  ] Yes     [  ] No
 
Have you filed a legal suit?......................................[  ] Yes     [  ] No



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: ___________________