Peregrine
Initial intake
Intake type
Initial intake
Chiropractic intake
Orthopedic intake
About you
First name
Last name
Date of birth
Phone
Email
Today's visit
Reason for visit
Date of accident or injury
Type of injury
Not recorded
Motor vehicle accident
Workers compensation injury
Slip/trip/fall
Sports injury
Other
Insurance for this visit
Not sure
No-Fault
Workers' Compensation
Major Medical / Medicare
Symptoms & what happened
Pain
Headaches
Stiffness
Swelling
Numbness / tingling
Weakness
Other / details
Pain & daily activity
Affected body parts
Head
Neck
Upper back
Low back
Shoulder
Arm / hand
Hip
Knee
More affected body parts
Leg / foot
Other / details
Pain level
Not recorded
0/10 - No pain
1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
10/10 - Worst pain
Occupation
Work status
Not recorded
Working full duty
Working modified duty
Not working due to injury
Not employed
Retired
Student
On disability
Activity limits
Triggers, relief & activity limits
Worse with sitting
Worse with standing
Worse with walking
Worse with stairs
Sleep affected
Daily activities limited
Other / details
Health history
Medical history
Diabetes
Hypertension
Asthma
Osteoarthritis
Rheumatoid arthritis
Heart disease
Thyroid disease
Depression / anxiety
Other / details
Allergies & reactions
Penicillin
Sulfa
Latex
Shellfish
Other / details
Medications & surgery
Current medications
Surgical history
Spine surgery
Shoulder surgery
Knee surgery
Hip replacement
Appendectomy
Cholecystectomy
Cesarean section
Hernia repair
Other / details
Prior care, imaging & family history
Emergency care
Emergency department
Urgent care
Ambulance transport
Discharged home
Other / details
Imaging already done
X-ray
MRI
CT
Other / details
Previous treatment
Physical therapy
Chiropractic care
Medication
Injection
Surgery
Home exercises
Other / details
Family history
Social history
Height
Weight
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