Age:   Date Of Birth: Occupation:

Marital Status:    M S W D       Spouse Name:

Employer:    Employers Address:

Is any other member of your family being treated at this office?    Yes No

Who referred you to this office?

Have you ever had chiropractic care before?     Yes No

If Yes, for what issue/problem?

Were the results satifactory?    Yes No N/A

Please list any major complaints or symptoms: (please be as specific as possible)

How do you believe your problem (pain) began? (please be as specific as possible)

When did you first notice the Problem / Pain?

Have you lost any work? Yes no Date you last worked

Ever had this condition before or a similar condition? Yes No If Yes, when?

What positions or activities aggravate your condition?

What positions or activities relieve your condition?

Have you been treated by a Medical Physician for the ailment? Yes No

If Yes, where?

Please describe the type of treatment

What was the diagnosis of the previous physician?

Length of time under their care? Results?

Your family physician's name:

Would you like a copy of your report sent to your family physician? Yes No

Will this be covered by an insurance company? Major Medical Auto Blue Cross/Blue Shield Workers Compensation Medicare None

Have you ever been in an accident, auto, a fall down stairs or ladder, etc? Yes No

If Yes, when?

Are you allergic to anything you are aware of? Yes No

Are you presently taking any medications (aspirin included)? Yes No

If Yes, please list them:

Have you ever broken any bones (fractures)? Yes No Any dislocations? Yes No

What operations have you had? Year?

What operations have you had? Year?

What operations have you had? Year?

Have you ever had any cosmetic surgeries, breast implants, etc? Yes No Year?

Have you ever had any surgery to replace a hip, knee, etc? Yes No Year?

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Give dates you have had any of the following:
(if exact date is unknown, give approximate date)

Blood Test Urinalysis

MRI CT Scan

Ultra Sound Radiation Treatment

X-Ray Examination Other Special Treatment

At what hospital or office were these tests taken?

Name of the doctor that ordered the tests:

Date of last menstrual period:

Do you have any reason to believe you might be pregnant? Yes No

Do you have any health problems not listed above? Yes No

Do you faint easily? Yes No

Do you take vitamins? Yes No If Yes, please list them:

Do you exercise regularly? Yes No If Yes, please list what types of exercise

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Habits:

Cigarettes? Quantity:

Coffee? Quantity:

Alcohol? Quantity:

Tea? Quantity:

List your hobbies:

Have you been treated for any health conditions by a physician in the past year? Yes No

If Yes, what condition?

Have you lost or gained weight in the past year? Yes No

Use this space for any additional information you may wish to discuss:

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Have you had, or do you now have, any of the following symptoms which are,
or have been, of significant distress to you?
Please indicate with the letter "N" if you have these conditions NOW (within the last 12 months) or
"P" if you ever had these conditions in the PAST (prior to the past 12 months)

Headaches                      P N                 Loss of Balance       P N
Neck Pain                        P N                 Fainting                   P N
Stiff Neck                         P N                 Loss of Smell           P N
Sleeping Problems          P N                 Loss of Taste           P N
Back Pain                        P N                 Diarrhea                  P N
Nervousness                   P N                 Feet Cold                P N
Tension                           P N                 Hands Cold             P N
Irritability                         P N                 Arthritis                    P N
Chest Pains                     P N                 Muscle Spasms      P N
Dizziness                         P N                 Frequent Colds       P N
Shoulder/Neck/Arm Pain P N                Stomach Upset        P N
Pins & Needles in Arms   P N                Constipation            P N
Pins & Needles in Legs   P N                Cold Sweats             P N
Numbness in Fingers      P N                Fever                       P N
Numbness in Toes          P N                Sinus Problems        P N
High Blood Pressure       P N                Diabetes                   P N
Difficulty Urinating           P N                Hemmorrhoids          P N
Allergies                          P N                Leg Cramps              P N
Weakness in Arms          P N                Colitis                        P N
Weakness in Legs           P N                Gall Bladder              P N
Shortness of Breath        P N                Indigestion                 P N
Fatigue                            P N                Belching                     P N
Deprssion                        P N                Shoulder Pain            P N
Loss of Memory               P N                Swelling Joints           P N
Ears Ring                         P N                Knee Pain                  P N
Face Flushed                   P N                Hay Fever                 P N
Buzzing in Ears                P N                Menstrual Difficulties P N

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I understand and agree that health and accident insurance policies are an agreement between the insurance carrier and myself, and that all services rendered me are charged directly to me, and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, and fees for professional services rendered me will be immediately due and payable.

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Do you have chest pains?                                                                       Yes No
Do you have any change in bowel or bladder habits?                            Yes No
Do you have a sore that does not heal?                                                 Yes No                 
Do you have any unusual bleeding or discharge?                                  Yes No
Do you have any thickening in your breasts or elsewhere?                    Yes No
Do you have indigestion or difficulty in swallowing?                                Yes No
Do you have a change in any wart or mole?                                          Yes No
Do you have a nagging cough or hoarseness?                                      Yes No
Do you have headaches for hours or days?                                           Yes No
Do you have blurred vision?                                                                   Yes No
Do you have night sweats?                                                                     Yes No
Do you have pain in neck, jaw, or face?                                                  Yes No
Do you have a drooping eyelid or any change in your pupils?                Yes No
Do you have vertigo (dizziness)?                                                            Yes No
Do you have double vision?                                                                    Yes No
Do you have any other visual disturbances?                                           Yes No
Do you have any nausea or vomiting?                                                    Yes No
Do you have any slurred speech?                                                           Yes No
Do you have any ringing in your ears?                                                    Yes No
Do you pass out easily (faint)?                                                                Yes No
Do you take birth control pills?                                                                Yes No
Do you have a history of stroke in your family?                                       Yes No

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What Prescriptions are you currently taking, if any?

High Blood Pressure Medication

Blood Thinners

Other

List Allergies or adverse reactions to medications.

Have you ever had cancer?                                                              Yes No                     
Does your pain ever wake you from a sound sleep?                        Yes No
Are you losing weight now without trying?                                         Yes No
Are you coughing up blood or noticing it in your stools or urine        Yes No
Have you had any loss of bladder or bowel control                          Yes No
Have you lost consciousness or had double vision recently            Yes No
Are you seeing any other doctor now for any reason?                     Yes No

If Yes, please list some breif notes:

Are you taking any medications or over-the counter drugs? Yes No

Please indicate type (aspirin, etc.)

What was the date of onset of your last menses?

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Has your mother or father had any of the following:
Select an M for mother, F for father and B for both

High Blood Pressure                       M F B
Pacemaker                                      M F B
Heart Attack                                    M F B
Ulcer or Stomach Problems            M F B
Emphysema                                    M F B
Stroke                                              M F B
Seizures-Convulsions                     M F B
Arthritis-Rheumatism                      M F B
HIV Positive                                     M F B
Mental Illness                                  M F B
Asthma                                            M F B
Thyroid Disease                              M F B
Diabetes                                          M F B
Circulation Problems                       M F B
Kidney Disease                               M F B
Osteoporosis                                  M F B
Cancer                                            M F B

 

You will be asked to sign this once you come in for your appointment

_______________________________________________________________________________
patient signature