University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com

Hello & Welcome from Dr. Kirk & Dr. Sandra. 

 

We are honored that you have given us the opportunity to help you with your health & well-being goals.  Whether it's a back ache, migraine or serious health condition we want to do what we can to help you & your family reach optimal health as soon as possible.

 

Please take the time to fill out these health questionaires as thoroughly as possible. After 23+ years in practice together we have found that the more thorough we are at the begining the best chance we have to help your body heal faster.  Thanks again for your trust in us.

 

After completing each section click the "Next" button at the bottom of the page.  Once completed your information with be automatically sent to our secure computer server/software.  We will not share any of your confidential inforamtion with anyone or any insurance company (life or health, etc) without your expressed permission.

 

Yours in Health

 

Dr. Sandra & Dr. Kirk

University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
First Name
Last Name
Address
City
Zip Code
Home Phone
Cell Phone
Other Phone
Email
Gender
SSN
Birthdate
Height
Weight
Shoe Size
Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit
Work Status
Employer
Employer Phone
Occupation
Employer Address
Have you missed work due to this injury?
Missed work start date
Return or anticipated return date
Extend. Health Cov.

Primary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Zip Code
State
Employer
Emp. Phone
Secondary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Zip Code
State
Employer
Emp. Phone
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
The symptoms that have prompted you to seek care today include:
Have you seen other doctor(s) for this condition?
Prior Interventions
What is the condition related to?
When did your problem first start?
Have you had this condition before?
Does the pain radiate or travel to other parts of the body?
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
Does anyone from your family suffer from the same condition?
What makes the condition worse?
What makes the condition better?
Does this condition affect employment?
Does this condition affect recreation?
Does this condition affect household?
Does this condition affect personal?
Does this condition affect sleep?
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
What else should we know about your current condition?
Rate the severity of your pain from 0 to 10

No Pain
Excruciating Pain
Pain Duration
Current Medications
Supplements
Sleep Position
Hours of sleep per night (1-24)
Have you had x-rays in the last six months?
I realize that x ray examinations may be hazardous to an unborn child. I certify to the best of my knowledge I am not pregnant.
Last Cycle:
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
Type of Pain
Front Head

Type of Pain
Front Face

Type of Pain
Front Left Jaw

Type of Pain
Front Right Jaw

Type of Pain
Front Right Neck

Type of Pain
Front Left Neck

Type of Pain
Front Left Chest

Type of Pain
Front Right Chest

Type of Pain
Front Right Ribs

Type of Pain
Front Left Ribs

Type of Pain
Front Abdomen

Type of Pain
Front Pelvis

Type of Pain
Front Right Hip

Type of Pain
Front Left Hip

Type of Pain
Front Right Thigh

Type of Pain
Front Left Thigh

Type of Pain
Front Right Knee

Type of Pain
Front Left Knee

Type of Pain
Front Right Lower Leg

Type of Pain
Front Left Lower Leg

Type of Pain
Front Right Ankle

Type of Pain
Front Left Ankle

Type of Pain
Top of Right Foot

Please specify specific areas

Type of Pain
Top of Left Foot

Please specify specific areas

Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

Type of Pain
Front Right Upper Arm

Type of Pain
Front Left Upper Arm

Type of Pain
Front Right Elbow

Type of Pain
Front Left Elbow

Type of Pain
Front Right Forearm

Type of Pain
Front Left Forearm

Type of Pain
Front Right Hand

Please specify specific areas

Type of Pain
Front Left Hand

Please specify specific areas

Type of Pain
Front Right Wrist

Type of Pain
Front Left Wrist

Type of Pain
Back of Head

Type of Pain
Back Right Neck

Type of Pain
Back Left Neck

Type of Pain
Upper Back

Type of Pain
Back Right Shoulder

Type of Pain
Back Left Shoulder

Type of Pain
Mid-Back

Type of Pain
Back Right Ribs

Type of Pain
Back Left Ribs

Type of Pain
Lower Back

Type of Pain
Back Right Hip

Type of Pain
Back Left Hip

Type of Pain
Back Right Glute

Type of Pain
Back left Glute

Type of Pain
Back Right Thigh

Type of Pain
Back Left Thigh

Type of Pain
Back Right Knee

Type of Pain
Back Left Knee

Type of Pain
Back Right Lower Leg

Type of Pain
Back Left Lower Leg

Type of Pain
Back Right Ankle

Type of Pain
Back Left Ankle

Type of Pain
Bottom of Right Foot

Please specify specific areas

Type of Pain
Bottom of Left Foot

Please specify specific areas

Type of Pain
Back Right Upper Arm

Type of Pain
Back Left Upper Arm

Type of Pain
Back Right Elbow

Type of Pain
Back Left Elbow

Type of Pain
Back Right Forearm

Type of Pain
Back Left Forearm

Type of Pain
Back Right Hand

Please specify specific areas

Type of Pain
Back Left Hand

Please specify specific areas

Type of Pain
Back Right Wrist

Type of Pain
Back Left Wrist

University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
Sensory
Integumentary
Endocrine
Genitourinary
General
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
Personal Illness History
Surgery/Trauma History
University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
Social History
Family History
Mother
Age
Age at Death
Health
Illness
Father
Age
Age at Death
Health
Illness
Sister
Age
Age at Death
Health
Illness
Brother
Age
Age at Death
Health
Illness

University Chiropractic
4015-K University Drive
Durham, NC 27707
(919) 493-1940
chiropracticuniversity@gmail.com
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?

Not Interested
Very Interested
How do you want us to handle your problem?
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Consent to treat patient

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Today's Date: 11 Dec 2017