Me Strong - 10 Years Stronger
Phone: (386) 337-3884

Chiropractic

DeLand Chiropractic Doctors

Corrective Chiropractic care for spinal misalignments, postural issues, and sports injuries.

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Ideal Protein Weight Loss & Nutrition

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"I tell everybody about the program because it really works."

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DRX 9000 Spinal Decompression

DRX 9000 Spinal Decompression Machine

A non-surgical, drug-free approach to severe neck and back pain.

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Re-Examination Form

Demographics, Medical History, Medication Update

 

Past Medical History

Current Medications / Supplements

Pain Disability Questionnaire

Instructions: These questions ask your views about how your pain now affects how you function in every day activities. Please answer every question and mark the ONE number on EACH scale that best describes how you feel.

1. Does your pain interfere with your normal work inside and outside the home?
Work Normally
Unable to work at all
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2
3
4
5
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7
8
9
10
2. Does your pain interfere with personal care (such as washing, dressing, etc.)?
Take care of myself completely
Need help with all my personal care
1
2
3
4
5
6
7
8
9
10
3. Does your pain interfere with your traveling?
Travel anywhere I like
Only travel to see doctors
1
2
3
4
5
6
7
8
9
10
4. Does your pain affect your ability to sit or stand?
No problems
Can not sit/stand at all
1
2
3
4
5
6
7
8
9
10
5. Does your pain affect your ability to lift overhead, grasp objects or reach for things?
No problems
Can not do at all
1
2
3
4
5
6
7
8
9
10
6. Does your pain affect your ability to lift objects off the floor, bend, stoop or squat?
No problems
Can not do at all
1
2
3
4
5
6
7
8
9
10
7. Does your pain affect your ability to walk or run?
No problems
Can not walk/run at all
1
2
3
4
5
6
7
8
9
10
8. Has your income declined since your pain began?
No decline
Lost all income
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2
3
4
5
6
7
8
9
10
9. Do you have to take pain medication every day to control your pain?
No medication needed
Need medication throughout the day
1
2
3
4
5
6
7
8
9
10
10. Does your pain force you to see doctors much more often than before your pain began?
Never see doctors
See doctors weekly
1
2
3
4
5
6
7
8
9
10
11. Does your pain interfere with your ability to see the people who are important to you?
No problem
Never see them
1
2
3
4
5
6
7
8
9
10
12. Does your pain interfere with recreational activities and hobbies?
No interference
Total interference
1
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4
5
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7
8
9
10
13. Do you need the help of your family and friends to complete everyday tasks?
Never need help
Need help all the time
1
2
3
4
5
6
7
8
9
10
14. Do you now feel more depressed, tense, or anxious than before your pain began?
No depression/tension
Severe depression/tension
1
2
3
4
5
6
7
8
9
10
15. Are there emotional problems caused by your pain that interfere with your family, social and or work activities?
No problems
Severe problems
1
2
3
4
5
6
7
8
9
10

Instrumental Activities of Daily Living Scale (I.A.D.L)

Choose the option below that best describes your ability:


Operates telephone on own initiative. Able to look up and dial numbers, etc.
Dials a few well-known numbers.
Answers telephone, but does not dial.
Does not use telephone at all.

Does personal laundry completely.
Launders small items.
All laundry must be done by others

Takes care of all shopping needs independently.
Shops independently for small purchases.
Needs to be accompanied on any shopping trip.
Completely unable to shop.

Travels independently on public transportation of drives own car.
Arranges own travel via taxi, but does not otherwise use public transportation.
Travels on public transportation when accompanied by another.
Travel limited to taxi or automobile with assistance of another.
Does no travel at all.

Plans, prepares and serves adequate meals independently.
Prepares adequate meals if supplied with the ingredients.
Heats, serves and prepares meals or is able to prepare meals, but does not maintain adequate diet.
Needs to have meals prepared and served.

Is responsible for taking medication in correct dosages at correct time.
Takes responsibility if medication is prepared in advance in seperate dosage
Is not capable of dispensing own medication.

Maintains house alone or with occasional assistance.
Performs light daily tasks such as dish washing, bed making, etc.
Performs light daily tasks unsuccessfully
Needs help with all home maintenance tasks.
Does not participate in any housekeeping tasks.

Manages financial matters independently (budgets, check writing, etc.)
Manages day-to-day purchases, but needs help with major purchasing, etc.
Incapable of handling money.
   Yes   No
   Yes   No
   Yes   No
   Yes   No
   Yes   No
   Yes   No
By checking this box, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.




Disclaimer

DeLand Chiropractic & Spinal Decompression complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. DeLand Chiropractic & Spinal Decompression does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.