Vista Healthcare-Chiropractic Follow Up Paperwork

Patient Information

Vista Healthcare Sports Spine and Injury Center - Physical Therapy & Chiropractic
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Email:*
example@example.com (This will be used to send you a copy of this paperwork)
Has your insurance changed?*

YesNo
Insurance Card Front Image:

Cancelof
Insurance Card Back Image:

Cancelof
Primary Insurance Payer:
Copay:
Insurance ID Number:
Insurance Group Number:
Subscriber Name:

First NameLast Name
Subscriber Date of Birth:

MonthDayYear
Date
Relationship to Subscriber:

Quadruple Visual Analogue Scale

Instructions: Please select the number that best describes the question being asked. Please indicate your average pain levels and pain at minimum/maximum using the last 3 months as your reference. If you have completed this form before, indicate your average pain level since the last time you completed this form.
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Headaches:
What is your pain right now?:
What is your typical or average pain?:
What is your pain level at its best?:
What is your pain level at its worst?:
What percent (%) of your awake hours is your pain at its worst?
Neck:
What is your pain right now?:
What is your typical or average pain?:
What is your pain level at its best?:
What is your pain level at its worst?:
What percent (%) of your awake hours is your pain at its worst?
Back:
What is your pain right now?:
What is your typical or average pain?:
What is your pain level at its best?:
What is your pain level at its worst?:
What percent (%) of your awake hours is your pain at its worst?