| Patient Data |
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Name *
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Date
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Email *
(Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.) |
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| Mailing Address |
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Address
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City
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State
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Zip
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Telephone (Home)
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Telephone (Work)
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Referred By
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Age
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Birth Date
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Social Security #
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Number of Children
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Occupation
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Employer
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Marital Status
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Spouse's Name
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Spouse's Occupation
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Spouse's Employer
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Spouse's Health Status
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Emergency Contact
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Phone
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| Current Complaints |
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Nature of Injury
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Please Describe
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Date of Injury
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Have you ever had same condition?
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If yes, when?
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List other practicioners seen for this injury/condition
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Have you ever been under chiropractic care?
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| Insurance Information |
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Name of party responsible for payment
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Phone
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Do you have health insurance?
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Name of company
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| Medical History |
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Have you been treated for any
conditions in the last year?
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If yes, please describe
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Date of last physical exam
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Is there a chance that you are pregnant?
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Have you had X-rays taken?
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What medications are you taking and for what conditions (Please list dosage and amounts, etc).
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What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).
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| Have you ever: |
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Broken bones?
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Briefly explain
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Been hospitalized?
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Briefly explain
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Been in auto accident?
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Had Sprains/Strains?
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Briefly explain
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Been struck unconscious?
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Briefly explain
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Had surgery?
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Briefly explain
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| Family History |
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Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)
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Do you experience pain every day?
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Do your symptoms interfere with daily life?
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Does pain wake you up at night?
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Are your symptoms worse during certain times of the day?
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Do changes in weather affect your symptoms?
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Do you wear orthotics?
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Do you take vitamin supplements?
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What activities aggravate your symptoms?
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| Habits |
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Alcohol
Moderate
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Coffee
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Tobacco
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Drugs
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Exercise
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Sleep
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Appetite
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Soft Drinks
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Water
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Salty Foods
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Sugary Foods
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Artificial Sweeteners
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| Have you ever suffered from: |
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Alcoholism |
Irregular Cycle |
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Allergies |
Kidney Infection |
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Anemia |
Kidney Stones |
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Arteriosclerosis |
Loss of memory |
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Arthritis |
Loss of balance |
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Asthma |
Loss of smell |
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Back Pain |
Loss of taste |
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Breast lump |
Lumps In Breast |
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Bronchitis |
Neck Pain or Stiffness |
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Bruise Easily |
Nervousness |
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Cancer |
Nosebleeds |
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Chest Pain/Conditions |
Pacemaker |
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Cold extremities |
Polio |
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Constipation |
Poor Posture |
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Cramps |
Prostate Trouble |
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Depression |
Sciatica |
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Diabetes |
Shortness of breath |
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Digestion Problems |
Sinus Infection |
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Dizziness |
Sleep problems/insomnia |
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Ears Ring |
Spinal Curvatures |
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Excessive Menstruation |
Stroke |
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Eye Pain/Difficulties |
Swelling of ankles |
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Fatigue |
Swollen Joints |
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Frequent Urination |
Thyroid Condition |
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Headache |
Tuberculosis |
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Hemorrhoids |
Ulcers |
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High Blood Pressure |
Varicose Veins |
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Hot Flashes |
Venereal Disease |
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Irregular Heart Beat |
Other:
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559-733-2478
