Do not use this form to contact us for administrative issues or for sales or advertising. It is only for appointments.

By submitting this form you are granting us permission to call you to schedule a chiropractic appointment with Dr. Dana Sibilla
at 1934 NE Broadway, Portland, Oregon.

If this is an emergency, do not use this form, but instead use your phone to call 9-1-1 or go to an Urgent Care center.

We will not leave detailed information on an answering machine. We will not respond by Email. If you do not hear from us within one business day, Please call the clinic at (503) 280-9759.

Submitting this information does not create a doctor-patient relationship, but we will maintain the confidentiality of your information according to HIPAA rules. If you do not schedule within 72 hours, this information will not be maintained. This form is Email. Email may not be secure, and might be able to be seen by others. If this is an issue for you, you should not use this form.

You must answer all of the following questions. If your answers don't fit in the boxes, or you can't answer the questions, please call us.

THIS FORM TAKES 1 TO 5 MINUTES TO COMPLETE. FILLING IT OUT COMPLETELY WILL SPEED YOUR INTAKE VISIT.

When you come in to the clinic, we may ask you to repeat some of this information.

I am requesting an appointment.
(Yes) (No) Advertisers or salespeople please DO NOT use this form to contact us.

Are you (the person filling out this form) the patient?
(Yes) (No) (We MUST hear from and be able to speak with actual patient).

I am a new patient. An established patient (I have seen Dr. Sibilla before).

Your Full Name:
E-mail Address:
Your Telephone Number:	(Note: we will not respond via email. We will call this number unless there is a problem.)
Your age:	(If you are under 18, A parental consent form is required before any treatment occurs).

What is your health problem? What is going on for you today? Describe:

Do you have an urgent need to be seen? As in, are you requesting to be seen as soon as possible?
yes no
Because of pain? yes no

If this was a health emergency, I would call 9-1-1 or go to Urgent Care.
I am not having a health emergency. I do know that no emergency services will be mobilized or rendered based on this email.
This is an emergency, and I understand you are not an emergency care facility. I should/will call 9-1-1 or go to urgent care.
I do not understand.

Do you have pain or discomfort? yes no
Please rate your issue on a scale of 1 to 10 :
1 (hardly any discomfort) 2 3 4 5 :( (sad face) "prevents some regular activities" 6 7 8 9 10 (worst pain ever)

What happened to bring this on? Did you fall or have an accident? Describe:

Did this happen while working? yes no

Was this a car accident? yes no

When did this episode/problem/accident/injury start?
Today Yesterday Days Week few weeks ago Month Months Year Years Youth

Has this happened before? no yes

If so, when? (click all that apply)
Yesterday Days Week few weeks ago Month Months Year Years Lifetime

Is your problem
on one side
on both sides of body
on one side and the center of your body?
only on the center line of your body?

Problem region is
on the top half of my body
on the bottom half of my body
Entire body or spine from head to tailbone

Do you have pain down your arm/arms?
yes no
Do you have pain in your hand/hands?
yes no

Do you have pain down your leg or legs?
yes no

Do you have pain in your foot/feet?
yes no

Is there numbness (lack of sensation) in your hand/hands?
yes no  
or in your foot/feet?
yes no

Does your pain stay constant? or does it change or "come and go"?
Does Dull pain become sharp with movement? yes no
Is your pain shooting pain (like lightning bolt)? yes no

Is your pain/discomfort:
sharp/stabbing/gripping/cramping (Makes you want to cry out, takes breath away, stops you)
Dull, burning, aching. stinging, tingling, soreness (it may make you groan)
Mild discomfort only, you barely notice it, or you can ignore it
No pain or discomfort

You have stiffness that restricts my movement or movement of a body part? yes no
You are stiff when you wake in the morning, even if you then loosen up? yes no

Can you walk or move around without a limp? yes no
Do you have paralysis (can't make a body part move at all)? yes no
Can people tell you are in pain by looking at you? It's obvious? yes no

Are you bleeding or bruised? yes no

Is this problem Getting Worse? Staying the same? Getting better?

Do you have a significant headache? yes no
If so, does the headache throb or pulse stay constant?
Is this headache related to neck pain or back pain, or is it independent?
Yes, it is related, one causes the other or at the same time. No, unrelated, they are separate, can have one without the other

Are you dizzy? yes no
Do you experience any visual issues, blurriness, spots before your eyes, sensitivity to light? yes no

Do you have sharp pain in your back when you take a deep breath? yes no
Do you have shortness of breath? yes no

Is your neck or back or shoulder frozen/stuck to one side? yes no

Are you taking any medications for this, including Advil, ibuprofen, Aspirin or Tyelnol?
yes no

Did you obtain these medications from a doctor, or obtain them yourself?
Doctor. Self. Had already from other/prior injury. Other

Can you do your regular daily activities at home?
Yes, all? Only some I have difficulties at home I can hardly take care of myself.

Can you work? Yes, I can do all my work Only some of my work I cannot work
Do you need a work note? Yes No

Have you ever seen a chiropractor before? no yes
For this problem? no yes

Have you had any type of treatment for this problem yet, or before? no yes

Have you had any X-Rays or MRI of this area, ever? no yes

How did you hear about the clinic?
Friend or Aquaintance
Yellow Pages
Advertisement/Promotion
Internet Search
Dex Online
Another Patient
Referral from Doctor
Please tell us who or where:

Do you have health insurance that covers Chiropractic?
Yes. No. I have insurance but don't know about coverage for chiropractic or alternative care.

Health Insurance Company: When we call you, we can begin to verify your coverage.

How do you plan to pay for care?
Payment in full at time of service? Cash/Check/Visa, MC or Debit. I understand there is a discount for cash/check payments on the same day.
Health Insurance
Car Insurance
Worker's Compensation

What is the best time to call you?
AM Afternoon/PM Evening Anytime

Is there anything else you think we need to know about you or about your problem?