New Patient Intake

Back and Neck Relief Care - Dr. Jack F. Sarro D.C. (385) 389-2095

5300 S 500 E, Suite 15, Washington Terrace, UT 84405

All fields with * must be answered in order to submit form.

• Patient Information

Patient Full Name

Date

Cell Phone

Full Address

Date of Birth

Age

Marital Status

Occupation and Employer

Emergency Contact

Referred to our office by?

• Pain Location

Which side is your pain on? Any other details about your condition

Pain began when and how?

• Quality of Your Pain

Does your pain radiate or travel?

Yes

Any numbness or tingling?

Yes

• Pain Scale

How often do you have it?

How long does it last?

What makes your pain better?

What makes your pain worse?

• Interferes With

• Previous Treatment and Testing

Outcome of Previous Care?

Previous Chiropractor?

• Auto or Work Accident Information

Is this condition due to an Auto or Work Accident?

Yes

• Past Health History

* If none, please type none or NA

Surgeries and Dates:

Hospitalizations and Dates:

Accidents, Injuries, or Trauma and Dates:

Broken Bones and Dates:

Allergies:

# of children?

Are you pregnant?

Yes

Date last menstrual period began?

• Medications

• Supplements

• Family Health History

Relationship, age, cause of death of close family members or mark NA if none:

• Social Health History

Education Level:

Job Description and Work Schedule:

Recreation and Hobbies:

Dietary Habits - Typical Diet:

Do you exercise? Frequency - Type?

Do you drink alcohol?

Do you smoke?

Do you take recreational drugs?

• Review of Health Systems

* Please check all symptoms you have currently or have experienced frequently in the past. Check None in each category if none.

• General Health

• Musculoskeletal System

• Skin Health

• Immune System

• Eyes, Ears, Nose, and Throat

• Cardiovascular System

• Pulmonary System

• Digestive System

• Urinary System

• Reproductive System

• Mammary System

• Hormonal System

• Lymphatic and Blood System

• Nervous System

• Mental Health Conditions

• Please Sign, Date Below, and Submit Form.

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Patient or Guardian Signature

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Date

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New Patient Intake

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PAIN RELIEF OFFICE HOURS