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Patient Information

Full Legal Name *

Date of Birth *

Gender

Male

Female

Marital Status *

Single
Married
Divorced
Widower/Widowed
In a domestic partnership
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Phone *

Email *

Address *

City *

State *

Postal code *

Emergency Contact Name and Phone Number *

Date *

Initial Problem Record

What is your main complaint or problem? *

How did this begin? *

When did this begin? *

Rate your complaint(s) today. If more than one complaint, fill up below: *

0 - None

1

2

3

4

5

6

7

8

9

10 - Worst

Complaint #2

Complaint #2 - When did this begin?

Complaint #2 - How did this begin?

Complaint #2 rating:

1 - None

2

3

4

5

6

7

8

9

10 - Worst

List Doctors (name & phone number or email) consulted for condition(s):

What makes your problem better?

What makes your problem worse?

Has this happened before?

Yes
No
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This problem bothers me:

Occasionally (0%-25% of the time)
Intermittently (25%-50% of the time)
Frequently (50%-75% of the time)
Constantly (75%-100% of the time)
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Do you have any other related or unrelated complaints you would like to address?

Mark whichever number correlates to the area(s) of complaints on the graphic above

1 (R Head)

2 (L Head)

3 (Neck)

4 (R Chest)

5 (L Chest)

6 (Upper R Arm)

7 (Upper L Arm)

8 (R Arm)

9 (Left Arm)

10 (R Hand)

11 (L Hand)

12 (R Ribs)

13 (L Ribs)

14 (R Stomach)

15 (L Stomach)

16 (Groin)

17 (R Thigh)

18 (L Thigh)

19 (R Leg)

20 (L Leg)

21 (R Foot)

22 (L Foot)

23 (R Head Back)

24 (L Head Back)

25 (Neck Back)

26 (R Shoulder)

27 (L Shoulder)

28 (R Upper Arm Back)

29 (L Upper Arm Back)

30 (R Arm Back)

31 (L Arm Back)

32 (R Hand Back)

33 (L Hand Back)

34 (R Mid Back)

35 (L Mid Back)

36 (L Lower Back)

37 (R Lower Back)

38 (R Buttocks)

39 (L Buttocks)

40 (L Thigh Back)

41 (R Thigh Back)

42 (R Leg Back)

43 (L Leg Back)

44 (R Foot Heel)

45 (L Foot Heel)

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Brain, Not Bone Alone

26302 La Paz Road, Suite 214

Mission Viejo, CA 92691

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