Initial Health Status ASHP

Initial Health Status

Gender*
Please select one option
Mark an X on the picture where you have pain or other symptoms.
Describe Your Current Problem and How It Began:
Is this?*
Please select one option
Current complaint (how you feel today):*
Please select one option
How often are your symptoms present?
In the past week, how much has your pain interfered with your daily activities (e.g., work, social activities, or household chores?*
Please select one option
In general would you say your overall health right now is:*
Please select one option
HAVE YOU HAD SPINAL X-RAYS, MRI, CT SCAN FOR YOUR AREA(S) OF COMPLAINT?*
Please select one option
Please check all of the following that apply to you:
Family History

I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this practitioner, I understand that I am liable for all charges for services rendered and I agree to notify this practitioner immediately whenever I have changes in my health condition or health plan coverage in the future. I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my physician, if necessary.

Patient Progress

Please complete the following three (3) questions regarding how you feel today.

MARK AN X ON THE PICTURE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS.
Current complaint:

2. Are you getting better?

In the past week, how much has your pain interfered with your daily activities (e.g., work, social activities, or household chores?*
Please select one option
In the past week, on average how often have your symptoms been present?
In general would you say your overall health right now is:*
Please select one option

3. Is there anything new?

Have you had any new complaints/conditions?*
Please select one option
Have you had any re-injuries or events that have prolonged your recovery?*
Please select one option

I certify that the above information is complete and accurate to the best of my knowledge. I agree to notify this practitioner immediately whenever I have changes in my health condition or health plan coverage in the future.

Thank you for taking the time to fill out this form.

Contact Us

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Our Location

801 South Escondido Blvd | Escondido CA, 92025

Office Hours

Find Out When We Are Open

Monday:

8:00 am-6:00 pm

Tuesday:

9:00 am-5:00 pm

Wednesday:

8:00 am-6:00 pm

Thursday:

9:00 am-12:00 pm

Friday:

8:00 am-6:00 pm

Saturday:

Closed

Sunday:

Closed