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PATIENT HISTORY QUESTIONNAIRE (for Chiropractic and Functional Medicine Patients) Date: Name: DOB: Age: Sex: M Address: City: State: Zip: S.S.N. Home Phone: Mobile: Employer: Occupation: Work Phone:
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How to fill out for chiropractic and functional

01
Start by gathering all necessary personal information such as name, address, date of birth, and contact details.
02
Next, ask the patient about their medical history, including any previous injuries, surgeries, or ongoing conditions.
03
Inquire about the specific reason for seeking chiropractic or functional treatment, such as back pain, joint mobility issues, or sports injuries.
04
Perform a thorough physical examination, assessing the patient's range of motion, muscular strength, and any areas of tenderness or discomfort.
05
Based on the examination findings, determine the appropriate treatment plan, which may include spinal adjustments, therapeutic exercises, or lifestyle modifications.
06
Clearly explain the treatment plan to the patient, detailing the goals, expected outcomes, and any potential risks or side effects.
07
Obtain informed consent from the patient before proceeding with any treatment procedures.
08
Document all findings, treatment procedures, and progress in the patient's medical record.
09
Regularly reassess the patient's condition and adjust the treatment plan as necessary.
10
Provide proper post-treatment care instructions, including home exercises, dietary recommendations, and any follow-up appointments.
11
Follow up with the patient to assess their progress and make any further adjustments to the treatment plan as needed.

Who needs for chiropractic and functional?

01
Chiropractic: Chiropractic care is beneficial for individuals experiencing back pain, neck pain, headaches, joint problems, musculoskeletal injuries, and overall body discomfort. It can also be helpful for those seeking natural and non-invasive approaches to healthcare.
02
Functional: Functional medicine is suitable for individuals with chronic diseases, autoimmune disorders, hormonal imbalances, gastrointestinal issues, metabolic disorders, and other complex health conditions. It focuses on identifying the underlying causes of illness and optimizing overall well-being.
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Chiropractic and functional refers to the practice and principles of chiropractic care combined with a functional approach to health, which emphasizes the body's ability to function optimally through various interventions.
Healthcare providers who offer chiropractic services and functional assessments are typically required to file for chiropractic and functional billing or reporting purposes, including chiropractors and relevant healthcare facilities.
To fill out for chiropractic and functional, providers need to complete the designated forms with accurate patient information, treatment details, and appropriate codes relating to chiropractic services or functional assessments.
The purpose of filing for chiropractic and functional is to ensure proper documentation and reimbursement for services provided, while also tracking patient outcomes and treatment efficacy.
Information that must be reported includes patient identification details, treatment codes, diagnosis codes, notes on the functional assessment, and any other relevant data regarding the patient’s care.
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