Intake Form

1
Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
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Austria
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The Bahamas
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Belize
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Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
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Burkina Faso
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Canada
Cape Verde
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Chad
Chile
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Christmas Island
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
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The Gambia
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Greece
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
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Kenya
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North Korea
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
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Sudan
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
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Vanuatu
Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
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Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Date of Birth* This field is required.
Date
Month
Day
Year
6
Profession
7
Medications & Supplements * This field is required.
Current Medications
Current Supplements
8
Who may we thank for referring you?
9
Choose Your Care* This field is required.Please select which type of care you are seeking
Chiropractic
Pediatric Chiropractic
Mercier Therapy
Both Chiropractic + Mercier Therapy
10
Are you on a special diet?If YES, please describe
11
How do you feel about your health in the category of NUTRITION?
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How do you feel about your health in the category of SLEEP?
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How do you feel about your health in the category of HYDRATION?
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How do you feel about your health in the category of EXERCISE?
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How do you feel about your health in the category of STRESS?
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Reason for Seeking Therapy* This field is required.
Natural Conception
IUI Prep
IVF Prep
Painful Periods
Other
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Reason for Seeking Therapy:
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Your Cycle
Frequency of Periods
Duration of Menses
Menarche (period onset)
Briefly describe your cycle (heavy, clots, pms, etc.)
19
Date of Last Menstrual Period
Date
Year
Month
Day
20
Do you experience pelvic pain?Answer YES if you have a history of pelvic pain
YESNO
21
Please describe the pain(ie. location, intensity, sensation, how it affects your daily activities and quality of life)
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When during your cycle do you experience pain?
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Have you received a medical diagnosis?
YESNO
24
Please list the diagnosis and the method that was used:(ie. Type of testing, imaging, etc.)
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Gynecological History
History of birth control use
Yes, no abnormalities
Yes, abnormalities found
Have not had an ultrasound
Current ultrasound results
History of sexual abuse
Pelvic/vaginal infections (and treatment)
26
GI History
List any intestinal problems
Frequency of bowel movements?
Yes
No
Blood noted in BM?
27
Have you had a positive pregnancy test before?
YESNO
28
Obstetric History
Miscarriage? (dates of occurrences)
Elective abortion? (dates of occurrences)
Childbirth? (vaginal and/or C-section)
Birth trauma? (please describe)
29
Have you gone through (or are you currently in) an IVF cycle?
YESNO
30
History of IVF: (give dates and type of drug used, how many eggs retrieved, how many embryos transferred, outcome)
Huge
Large
Normal
Small
Ok
Ok
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Have you done (or are you planning to do) a medically assisted fertility cycle?
YESNO
32
History of medically assisted fertility cycles: (dates, type of cycle, outcome)
Huge
Large
Normal
Small
Ok
Ok
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Have you had any of the following surgeries?
Gynecological surgery (OTHER than IVF or IUI)
Abdominal surgery
Urinary surgery
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Describe surgery dates and details:
35
Thank you for taking the time to answer the questions regarding your upcoming Mercier Therapy appointment. During your visit the doctor will discuss your history with you, evaluate your general pelvic movement and check the position and mobility of your uterus and ovaries. From there, a plan for further care will be made if you are a candidate for Mercier Therapy.

We look forward to serving you!
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Basic Information
Age
Single
Married
Divorced
Separated
Widowed
Marital Status
Height
Weight
Number of hours at a desk
Repetitive Movements
37
Reason for Seeking Chiropractic Care* This field is required.(If there is more than one, please list them in order of importance)
38
Have you been treated before for this problem?
YESNO
39
What type of care did you receive?
40
Concerning the primary issue, when did you first experience symptoms?
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What is your pain level today?Slide to describe how you are feeling today
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What is your pain level when it is most severe?
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What is your pain level on average?Slide to describe how you are feeling today
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Details about your condition
Suddenly
Gradually
Symptoms occur suddenly or gradually?
Option 1
Option 2
Option 3
Is it getting worse?
Local pain or does it radiate?
What worsens it? (ie. sitting, etc.)
Is it constant? How often?
What gives relief?
Describe your symptoms (sharp, achy, throbbing, dull, etc.)
45
Does your condition interfere with any of the following?Check all that apply
Work
Sleep
Daily Routine
Recreation
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Have you had chiropractic care in the past?
YESNO
47
What reason(s) did you receive care?
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Please list all surgeries and/or hospitalizations that you have undergone with reasons and corresponding dates:
Huge
Large
Normal
Small
Ok
Ok
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Please describe any serious accidents or injuries with corresponding dates (fractures, car accidents, sports injuries, falls, trauma):
Huge
Large
Normal
Small
Ok
Ok
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List the types and dates of any major illnesses:
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List any problems with PMS or your menstrual cycle:
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Do you feel like you have a strong pelvic floor? Why or why not?
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Do you experience any incontinence? If so, when?
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Do you experience any pelvic pain? If so, when?
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How many pregnancies have you carried?
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Have you ever had an episiotomy?
YESNO
57
Have you ever had diastasis?
YESNO
58
Do you have difficulty taking deep breaths?
YESNO
59
Do you experience allergies? If so, which ones and when did they start?
60
Please upload any images or files here:
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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What are your health goals?Choose all that apply
More energy
Better concentration
Improved flexibility
Strengthening immune system
Easier breathing
Better sleep
Improved strength
Lessening stress
Less pain throughout the day
62
Do you smoke?
YESNO
63
Do you drink alcohol?
YESNO
64
Do you drink caffeine?
YESNO
65
Do you exercise?
YESNO
66
What is your sleeping position?
Side
Back
Stomach
Toss & turn
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What are your hobbies?
68
What do you do to relax?
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Use the space below to elaborate on your condition or give any information that may have been missed in the above questionnaire:
Huge
Large
Normal
Small
Ok
Ok
70
Reason for Seeking Chiropractic Care* This field is required.(If there is more than one, please list them in order of importance)
71
Have you seen another practitioner for this condition?
YESNO
72
Which kind of practitioner? Please describe the treatment.
73
Is the problem:
Constant
Intermittent
Occasional
Cyclic
74
How long has the problem persisted?
75
When it is at its worst, how does it make your child feel?
76
What have you done about it that has NOT worked?
77
What makes it worse?
78
What effect does this problem have on your child's bodily functions/daily activities?
79
Describe any hospital stays:
80
Medication
Present prescription drugs
Past prescription drugs
Rounds of antibiotics in the last 6 months?
Rounds of antibiotics in their lifetime?
Over the counter drugs (past 6 months)
81
Were there any complications during the pregnancy?
82
Was your baby full term?
YESNO
83
Was your baby breech?
YESNO
84
Where was your baby born?
Hospital
Home
Birth Center
85
Labor Questions
Was labor induced?
Forceps/Vacuum delivery?
Length of labor?
Delivery complications?
Any pain meds during delivery (ie. epidural)?
C-section or VBAC? Planned?
86
Signature
Clear
87
Feeding Questions
Was baby breastfed?
How many months?
Issues with latch?
Preference of a side?
Arching back/neck?
88
According to the National Safety Council, approximately 54% of infants fall head first from a high place (bed, changing table, etc.) during the first year of life. Has this happened to your child? Y/N? Comments.
89
Please list any other falls or accidents
90
Check any of the following conditions your child has suffered from (past or present):
Ear infections
Headaches
Chronic colds
Growing/back pains
Constipation
Scoliosis
Asthma/allergies
ADD/ADHD
Colic
Head banging
Seizures
Digestive problems
Recurring fevers
Bedwetting
Reaction to vaccination(s)
Sleeping problems
Did not gain weight
Autism
Learning difficulty
91
Does your child participate in sports? If yes, please list
92
Use the space below to elaborate on your condition or give any information that may have been missed in the above questionnaire:
Huge
Large
Normal
Small
Ok
Ok
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Please sign below:
Clear
94
Thank you for taking the time to let us understand more about you, see you soon!
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