Back Disorder Medical Intake Form
Please complete this intake form before your back disorder evaluation. Share your current symptoms, history, and any warning signs so the care team can review your case.
Patient Information
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Back Disorder Intake
Main reason for visit / primary back concern
*
Pain location
*
Upper back
Mid back
Lower back
Neck and back
Other
Pain severity
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Symptom duration
*
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Symptoms experienced
Stiffness
Shooting pain
Numbness
Tingling
Weakness
Reduced mobility
Other
Prior treatments tried
Rest
Medication
Physical therapy
Chiropractic care
Heat/Ice
None
Other
Current medications related to the back issue
Additional notes or concerns
Red Flag Screening
Fever or chills?
*
No
Yes
Unexplained weight loss recently?
*
No
Yes
Recent injury or trauma to your back?
*
No
Yes
Loss of bladder or bowel control?
*
No
Yes
Numbness or tingling in the groin or saddle area?
*
No
Yes
Pain that wakes you from sleep?
*
No
Yes
If any warning sign is yes, describe the most concerning symptom or event and when it started
Submit
Should be Empty: