Patient Forms, Questionnaires, and Handouts

PATIENT INTAKE FORMS

Forms to fill out when you first come to the office. Dr. Lew likes to take a look into what may be behind your discomfort in terms of your daily activities and other factors in your life. She will review these forms with you to help create a treatment approach that best fits you and your needs.

Click on the Patient intake form and the Pain Diagram/History of Issue form links below to get a PDF of the documents.

 

OUTCOME ASSESSMENT TOOLS (OATs)

Questionnaires to see how you are doing. These are questions about how your discomfort affects your life at home, at work, etc. There are separate questionnaires for the neck, low back, knee, ankle, foot, shoulder, elbow, wrist, and hand. There are also questionnaires or surveys on how you feel about your injury- for instance do you fear your pain will never go away? Or do you fear doing certain activities due to past traumas? That last one is called “kinesiophobia” and it can cause “fear avoidance”.

Dr. Lew will ask you to fill out the appropriate forms after she’s had your discovery phone call with you. These forms can be long and a bit tiresome, but they are very helpful to help you realize your dream of feeling and moving better! It’s also amazing when you have taken a questionnaire before and after a few treatment sessions or weeks of exercises and stretches because you often don’t realize how much you have improved.

The two most common reasons why a person comes to a chiropractor is low back pain and neck and upper back pain. Click on the links below to get a PDF of the questionnaires for these two areas.

HOME EXERCISE PROGRAMS (HEPs)

Exercises and stretches that can help you get moving!

Dr. Lew will pick and choose exercises and stretches to provide the best match for you during your recovery. She will be assessing to see when you are ready for the next level or tier or if you need to back down a bit on your exercise programs.

Dr. Lew will give you printed handouts (that you can keep or take a photo of) of the home exercise programs she will design for you. These will go with your one on one instruction of how to do the stretches and exercises to best help you recover optimum mobility.

Here are a few of the basic home exercise programs that Dr. Lew gives out that are designed to help you get started on your journey to recovery.

  • Modified Thread the Needle / Wing to the Sky Stretch

  • Glute Bridges with micro-steps

  • Quadruped with micro-steps

  • Side Bridges

  • Plank Rolling on incline

PATIENT INTAKE FORMS

This is a picture of a patient intake form that asks for patient details including Patient information, medical history, and details about the current chief complaint.
This is a picture of a pain diagram and history of chief complaint form. There is a picture of a body for people to mark as well as questions about what makes the complaint feel better or worse and so on.

SAMPLE OUTCOME MEASURE

This is a picture of the NDI or neck disability form where the patient is asked to talk about how activities of daily living are affected by their neck pain.

SAMPLE HOME EXERCISES

Dr. Lew is showing the “Smell the Armpit Stretch” to loosen the back and side of the neck. She puts her hand on her head and turns her nose to the armpit. Then she turns her head to look up and away. Great for sore necks!
Dr. Lew is showing a standing stretch sequence of Pray (pushing hands together), Yes (arms up in a letter Y), Thanks (letter T, palms up), and empty pockets (palms forward by the hips). A great stretch for the chest and sore shoulders!

Note: When you click on the patient form buttons, you will be taken to another webpage to a PDF.

Please download it and fill it out (print and write or fill out and print). That way it will save some time when you come to your visit with Dr. Lew.