On The Move Chiropractic
Auto Accident History
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Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Insurance Info
Insurer's Name
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Adjuster's Name
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Policy Number
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Office Address
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Unit #
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City
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Country
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Prov / State
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Postal Code / Zip
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Phone
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Fax
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Email Address
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Claims / Benefit
Conditions
Accident Info
Date of Injury
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Which State?
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MVA Claim
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Workers Comp Claim
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Crime Victim Comp.
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General Injury Related Questions
Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Sinus
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Tension
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Chronic Daily Headache
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Cluster
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Headaches
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Migraines
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Rebound
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Other Headaches
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Musculoskeletal
Strain/Sprain
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Dupuytren's Contracture
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Joint Stiffness / Swelling
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Adhesive Capsulitis
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Plantar Fasciitis
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Bone or Joint Disease
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Temporomandibular Joint Dysfunction
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Ehlers-Danlos Syndrome
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Muscular Dystrophy
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Amyotrophic Lateral Sclerosis (ALS)
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Psoriatic Arthritis
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Broken Bone / Fracture
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Fibromyalgia
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Myasthenia Gravis
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Ankylosing Spondylitis
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Recti Diastasis
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Chronic Fatigue Syndrome
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Torticollis
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Fracture
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Osgood-Schlatter Disease
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Arthritis
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Scleroderma
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Chronic Myofascial Pain Syndrome
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Whiplash
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Gout
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Osteoarthritis
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Artificial Joints / Special Equipment
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Scoliosis
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Compartment Syndrome
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Hereditary/Congenital Deformity
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Osteomalacia
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Baker's Cyst
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Sinus Problems
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Spasms / Cramps
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Degenerative Disk Disease
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Jaw Pain (TMJD)
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Osteoporosis
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Bone Disease
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Spondylolisthesis
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Dislocation
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Joint Injury
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Paget Disease
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Other Musculoskeletal
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Neurological
Shingles
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Brain Injury
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Transient Ischemic Attacks (TIA)
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Chronic Pain Disorder
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Loss of Sensation
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Shingles / Herpes
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Burning
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Twitching of Face
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Dizziness
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Multiple Sclerosis
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Numbness
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Sleeping Disorders
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Carpal Tunnel
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Vertebral and Spinal Cord Injury
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Dural Ectasia
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Parkinsons
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Stabbing
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Cerebral Palsy
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Epilepsy
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Peripheral Neuropathy
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Stroke
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Cerebral Vascular Accident (Stroke)
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Fatigue
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Post Polio Syndrome
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Syringomyelia
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Cerebral-vascular Accident
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Fibromyalgia
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Sciatic Pain
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Bell's Palsy
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Tethered Cord
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Cerebrospinal Fluid Leak
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Herniated Disc
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Seizure Disorder
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Brain Disorder
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Tingling
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Chiari Malformation
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Huntington Disease
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Other Neurological
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Brain Disorders
Depression
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PTSD
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Anxiety
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Other Psychological
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Health Questions
Epilepsy
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Meniere Disease
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Vertigo
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Asthma
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Gastrointestinal
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Migraines/Headaches
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Blood thinner medication
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Cancer
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Hearing Impairment
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Mood Disorder
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Cardiovascular
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Heart Attack
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Pacemaker
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Concussion
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Heart Condition
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Past Heart Surgery
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Congenital Heart Defect
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High blood pressure
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Schizophrenia
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Depression
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HIV/Aids
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Stroke
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Diabetes
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Low blood pressure
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Varicose veins
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Family History
Arthritis
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Cancer
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Cardiovascular
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Diabetes
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Respiratory
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Energy Level
Fatigue
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Flat
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High
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Agitated
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Low
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Chaotic
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Vibrant
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Clear
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Dull
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Even
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Hearing
Tinnitus
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Vertigo
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Other Hearing
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Miscellaneous
Other Medical Conditions
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Other Diagnosed Diseases
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Physical Activities You Participate In
Rugby
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Weight Lifting
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Basketball
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Running
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Yoga
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Crossfit
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Football
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Soccer
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Golf
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Softball
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Hockey
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Swimming
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Lacrosse
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Tennis
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Marathon
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Triathlon
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Baseball
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Pilates
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Waterpolo
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Other Activities
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Number of Times of Week You Practice
Once a week
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2-4 times a week
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More than 4 times a week
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Less than a couple of times a month
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Treatment Goals
Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Pain Relief
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Rehabilitation
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Other
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