Patient Data
Name *
Date
Email *
(Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.)
Mailing Address
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Telephone (Home)
Telephone (Work)
Referred By
Age
Birth Date
Social Security #
Number of Children
Occupation
Employer
Marital Status
Spouse's Name
Spouse's Occupation
Spouse's Employer
Spouse's Health Status
Emergency Contact
Phone
Current Complaints
Nature of Injury
Auto
Work
Other
Please Describe
Date of Injury
Have you ever had same condition?
No
Yes
If yes, when?
List other practicioners seen for this injury/condition
Have you ever been under chiropractic care?
No
Yes
Insurance Information
Name of party responsible for payment
Phone
Do you have health insurance?
No
Yes
Name of company
Medical History
Have you been treated for any
conditions in the last year?
No
Yes
If yes, please describe
Date of last physical exam
Is there a chance that you are pregnant?
No
Yes
Have you had X-rays taken?
No
Yes
What medications are you taking and for what conditions (Please list dosage and amounts, etc).
What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).
Have you ever:
Broken bones?
No
Yes
Briefly explain
Been hospitalized?
No
Yes
Briefly explain
Been in auto accident?
No
Yes
Had Sprains/Strains?
No
Yes
Briefly explain
Been struck unconscious?
No
Yes
Briefly explain
Had surgery?
No
Yes
Briefly explain
Family History
Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)
Do you experience pain every day?
No
Yes
Do your symptoms interfere with daily life?
No
Yes
Does pain wake you up at night?
No
Yes
Are your symptoms worse during certain times of the day?
No
Yes
Do changes in weather affect your symptoms?
No
Yes
Do you wear orthotics?
No
Yes
Do you take vitamin supplements?
No
Yes
What activities aggravate your symptoms?
Habits
Alcohol
None
Light
Moderate
Heavy
Coffee
None
Light
Moderate
Heavy
Tobacco
None
Light
Moderate
Heavy
Drugs
None
Light
Moderate
Heavy
Exercise
None
Light
Moderate
Heavy
Sleep
None
Light
Moderate
Heavy
Appetite
None
Light
Moderate
Heavy
Soft Drinks
None
Light
Moderate
Heavy
Water
None
Light
Moderate
Heavy
Salty Foods
None
Light
Moderate
Heavy
Sugary Foods
None
Light
Moderate
Heavy
Artificial Sweeteners
None
Light
Moderate
Heavy
Have you ever suffered from:
Alcoholism
Irregular Cycle
Allergies
Kidney Infection
Anemia
Kidney Stones
Arteriosclerosis
Loss of memory
Arthritis
Loss of balance
Asthma
Loss of smell
Back Pain
Loss of taste
Breast lump
Lumps In Breast
Bronchitis
Neck Pain or Stiffness
Bruise Easily
Nervousness
Cancer
Nosebleeds
Chest Pain/Conditions
Pacemaker
Cold extremities
Polio
Constipation
Poor Posture
Cramps
Prostate Trouble
Depression
Sciatica
Diabetes
Shortness of breath
Digestion Problems
Sinus Infection
Dizziness
Sleep problems/insomnia
Ears Ring
Spinal Curvatures
Excessive Menstruation
Stroke
Eye Pain/Difficulties
Swelling of ankles
Fatigue
Swollen Joints
Frequent Urination
Thyroid Condition
Headache
Tuberculosis
Hemorrhoids
Ulcers
High Blood Pressure
Varicose Veins
Hot Flashes
Venereal Disease
Irregular Heart Beat
Other: