Our Location

Re-Exam Intake Form

Chiropractic Family Wellness Center

1747 Smizer Station Rd Suite 5
Fenton, MO 63026
Phone: (636) 825-6555

What type of complaint?*
Please select at least one option
GIVE DETAILS: How were you injured?*
Please select one option
Frequency of pain?*
Please select one option
Describe the discomfort/pain:*
Please select at least one option
If the discomfort radiates, where does travel to? Otherwise, choose NON-RADIATING.*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
On a scale of 1 to 10 (with 10 being the worst), rate your pain:*
Please select one option
Symptom relieved by?*
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What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Have you received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
Activity of daily living most affected*
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What do you have difficulty performing due to this specific complaint? (Choose all the apply)*
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What are your specific therapeutic goals?*
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Do you have any other health concerns or complaints?*
Please select one option
What type of complaint?*
Please select at least one option
GIVE DETAILS: How were you injured?*
Please select one option
Frequency of pain?*
Please select one option
Describe the discomfort/pain:*
Please select at least one option
If the discomfort radiates, where does travel to? Otherwise, choose NON-RADIATING.*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
On a scale of 1 to 10 (with 10 being the worst), rate your pain:*
Please select one option
Symptom relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Have you received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
Activity of daily living most affected*
Please select at least one option
What do you have difficulty performing due to this specific complaint? (Choose all the apply)*
Please select at least one option
Do you have any other health concerns or complaints?*
Please select one option
What type of complaint?*
Please select at least one option
GIVE DETAILS: How were you injured?*
Please select one option
Frequency of pain?*
Please select one option
Describe the discomfort/pain:*
Please select at least one option
If the discomfort radiates, where does travel to? Otherwise, choose NON-RADIATING.*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
On a scale of 1 to 10 (with 10 being the worst), rate your pain:*
Please select one option
Symptom relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Have you received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
Activity of daily living most affected*
Please select at least one option
What do you have difficulty performing due to this specific complaint? (Choose all the apply)*
Please select at least one option
Do you have any other health concerns or complaints?*
Please select one option
What type of complaint?*
Please select at least one option
GIVE DETAILS: How were you injured?*
Please select one option
Frequency of pain?*
Please select one option
Describe the discomfort/pain:*
Please select at least one option
If the discomfort radiates, where does travel to? Otherwise, choose NON-RADIATING.*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
What is your pain on a scale of 1-10 (10 being the worst)?*
Please select one option
Symptom relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Have you received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
Activity of daily living most affected*
Please select at least one option
What do you have difficulty performing due to this specific complaint? (Choose all the apply)*
Please select at least one option
Do you have any other health concerns or complaints?*
Please select one option
What Musculoskeletal issues reported?*
Please select at least one option
What neurological are issues reported?*
Please select at least one option
What Head and ENT issues are reported?*
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What cardiovascular issues are reported?*
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What respiratory issues are reported?*
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What gastrointestinal issues are reported?*
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What genitourinary issues are reported?*
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What endocrine issues are reported?*
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What dermatological or hemopoietic issues are reported?*
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What allergy or sensitivity issues are reported?*
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Surgical history?*
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Drugs and medication(s)?*
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Name past illnesses:*
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Past history of accidents or trauma?*
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Immediate Family Health History?*
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what is the present work status of the patient?*
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Social habits?*
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Exercise routine?*
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Diet and nutrition?*
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Our office offers Functional Medicine. Are you interested in having a consultation for this service?

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Office Hours

Monday  

8:00 am - 6:00 pm

Tuesday  

8:00 am - 6:00 pm

Wednesday  

8:00 am - 6:00 pm

Thursday  

8:00 am - 6:00 pm

Friday  

8:00 am - 5:00 pm

Saturday  

Closed

Sunday  

Closed