Since the major goal of Cenk Corrective Care™ is to restore every patient to their "normal" functional capacity (considering age, sex, occupation, etc.), it is imperative that care begin with a specific and objective assessment of your current functional status. The Cenk Functional Assessment™ is comprised of 22 separate physical tests and biomechanical evalutions that measure and document your current health status in several key categories.
After you submit your Assessment Questionnaire, you'll see a "Form Submitted" verification of the information you provided to us. You can then print the Form Submitted page for your records and return here by selecting "Click to Continue" at the bottom of your Form Submitted page.
* Fields marked with an asterisk are required fields
* Name
* Email
* Street Address
* City
* State
* ZIP
* Occupation
Employer Name
* Home Number
Work Number
Cell Number
* Date of Birth
Married?
Spouse's Name
Number of Children
* Preferred Method of Contact
Regular Mail
Email
Home Number
* Office Location (Choose One) Fox Chapel Harmarville Gibsonia
* How did you become aware of Cenk Chiropractic? (Choose One) Website Newspaper New Member - Alexander's Athletic Club Referral from Physician Referral from Alexander's Staff Referral from Cenk Patient Referral from other individual Health Screening Other
If you chose referral, who made the referral?
If you chose other, please describe...
Insurance Company
ID Number
* Primary Complaint (please describe)
Secondary Complaint (please describe)
Select
Asthma
Chest Pain
Shortness of Breath
Stroke
Hernia
Pregnant
Numbness or Paralysis
Allergies
Heart Disease
Heart Disease-family member
Diabetes
Diabetes-family member
High Blood Pressure
High Blood Pressure-family member
Low Blood Pressure
Low Blood Pressure-family member
Pain in Shoulders
Pain in Arms
Pain in Hands
Pain in Hips
Pain in Legs
Pain in Knees
Pain in Feet
Numbness or Tingling in Shoulders
Numbness or Tingling in Arms
Numbness or Tingling in Hands
Numbness or Tingling in Hips
Numbness or Tingling in Legs
Numbness or Tingling in Knees
Numbness or Tingling in Feet
Lower Back Pain or Stiffness
Mid Back Pain or Stiffness
Neck Pain or Stiffness
Muscle Pain or Stiffness
Pain or Stiffness Between Shoulders
Pain or Stiffness in Arm / Elbow / Wrist / Hand
Pain or Stiffness in Leg / Hip / Knee / Ankle / Foot
Jaw Pain or Clicking
Fatigue / Loss of Energy
Irritability
Sinus Problems
Heartburn
Sleep Problems
Stress
Headaches
Other Problem(s)
If Other Please Describe
* Are there any injuries for which you have received treatment within the last 12 months?
Yes
No
If yes, where did the injuries occur?
at home
at work
in auto
Please provide details about the injury and its location...
* Are you currently under the care of any medical doctor?
yes
no
Medical Doctor's Name
Medical Doctor's Phone Number
Date of Last Visit
Reason for Last Visit
Do we have your permission to send an initial report to your PCP?
* Did you have previous chiropractic care?
Chiropractic Doctor's Name
Chiropractic Doctor's Phone Number
Date of Last Adjustment
Were X-Rays taken?
Date X-Rays Taken
* Do you take any prescription medicine?
If yes, please list...
Condition(s) for which medicine is prescribed?
* Are you taking any "over the counter" medicine?
If yes, please list and indicate why you are taking them...
* Are you taking any dietary suplements?
If yes, for any specific activity?
* How often do you exercise per week?
* Do you want to lose weight?
If yes, how much (in pounds)?
If yes, what do you consider your "ideal" weight (in pounds)?
* Do you want to improve your balance and coordination?
If for a specific activity, please describe...
* How many ounces of water do you drink per day?
* How many cups of coffee/tea do you drink per week?
* How many cans of soda do you drink per day?
* How many cans of diet soda do you drink per day?
Is there a possibility that you may be pregnant?
