Personal Information

NAME:

BIRTH DATE:

AGE:

ADDRESS:

CITY:

STATE:

ZIP:

CELL PHONE:

WORK PHONE:

HOME PHONE:

E-MAIL:

GENDER:

Male

Female

REFERRED BY:

MARITAL STATUS:

SINGLE

MARRIED

DIVORCED

WIDOWED

SPOUSE/PARTNER NAME:

OCCUPATION:

EMPLOYER:

PRIMARY CARE PHYSICIAN:

PHONE #:

EMERGENCY CONTACT INFORMATION

CONTACT NAME:

CONTACT PHONE:

RELATIONSHIP:

IS CONDITION:

JOB RELATED

AUTO ACCIDENT

HOME INJURY

FALL

OTHER:

Current Health Condition

SPECIFIC PURPOSE OF THIS APPOINTMENT:

IF YOU HAVE PAIN, DOES IT TRAVEL OR RADIATE ANYWHERE ELSE IN YOUR BODY?

Yes

IF YES, WHERE DOES IT TRAVEL / RADIATE TO?

PLEASE MARK YOUR PROBLEM AREAS ON THE DIAGRAM BELOW:

HOW DID IT START?

GRADUALLY

SUDDENLY

HAS THIS PROBLEM OCCURRED BEFORE?

Yes

IF YES, WHEN?

IF YES, WHAT DID YOU DO AND WHAT WAS THE OUTCOME?
DID ANYTHING CONTRIBUTE TO THE ONSET OF YOUR PROBLEM?
DOES THIS CONDITION NEGATIVELY AFFECT YOUR:

OTHER:
HOW OFTEN DO YOU EXPERIENCE YOUR PROBLEM (E.G. DAILY, ONCE PER WEEK, ETC.)?

DOES ANYTHING MAKE YOUR PROBLEM WORSE (E.G. SITTING, STANDING, BENDING, ETC.)?
DOES ANYTHING MAKE YOUR PROBLEM BETTER?
HAVE YOU HAD ANY CHANGES IN BODILY FUNCTIONS (BOWEL / BLADDER CONTROL, BREATHING, ETC.)?

Yes

IF YES, PLEASE EXPLAIN:

ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING:

MUSCLE WEAKNESS

NUMBNESS

DIZZINESS

NAUSEA

HEADACHES

DIFFICULTY SPEAKING

DIFFICULTY SWALLOWING

VISION PROBLEMS

IF YES, PLEASE CIRCLE SYMPTOMS ABOVE AND EXPLAIN:
HAVE YOU SEEN ANY OTHER HEALTHCARE PROFESSIONALS FOR THIS CONDITION?

IF YES, WHO AND WHEN?
PLEASE LIST ANY OTHER PERSISTENT MEDICAL CONDITIONS YOU SUFFER FROM:

Previous Chiropractic Care

HAVE YOU EVER RECEIVED CHIROPRACTIC CARE?

IF YES, FOR WHAT PROBLEM:

DATE OF LAST VISIT:

DOCTOR'S NAME:

HOW LONG WERE YOU UNDER CARE?

HOW WAS YOUR EXPERIENCE?

Past Health History

MAJOR INJURIES / TRAUMAS / SURGERIES / HOSPITALIZATIONS:

DO YOU HAVE ANY IMPLANTED SURGICAL DEVICES? (E.G. PACEMAKER, SURGICAL CLIPS, IUD, RODS / PINS / SCREWS, JOINT REPLACEMENTS, HEART VALVES, SHUNT / STENT, JOINT REPLACEMENT, INSULIN PUMPS, ETC.)?

IF YES, PLEASE DESCRIBE:
DO YOU HAVE A HISTORY OF STROKE, HIGH BLOOD PRESSURE, HEART DISEASE, CANCER OR DIABETES?

IF YES, PLEASE CIRCLE ALL THAT APPLY & DESCRIBE TREATMENT AND OUTCOMES:
HAVE YOU GAINED OR LOST ANY WEIGHT WITHIN THE LAST 6 MONTHS WITHOUT TRYING?

PLEASE LIST ALL PRESCRIPTION DRUGS, OVER-THE-COUNTER DRUGS AND / OR SUPPLEMENTS YOU CURRENTLY TAKE & THE REASON FOR TAKING THEM:

Social History & Habits

HOW STRESSFUL IS YOUR JOB / SCHOOL?

HOW STRESSFUL IS YOUR PERSONAL / HOME LIFE?

DO YOU SMOKE OR USE ANY TOBACCO PRODUCTS?

IF YES, HOW MUCH PER DAY / WEEK:

DO YOU CONSUME ALCOHOL?

IF YES, HOW MANY DRINKS PER DAY / WEEK / MONTH:

DO YOU CONSUME CAFFEINE?

IF YES, HOW MANY CUPS PER DAY / WEEK:

HOW MANY HOURS OF SLEEP DO YOU AVERAGE PER DAY?

DO YOU HAVE A REGULAR EXERCISE PROGRAM?

IF YES, WHAT TYPE, HOW OFTEN AND HOW INTENSE?

WHAT DO YOU LIKE TO DO FOR RECREATION (I.E. HOBBIES, SPORTS, ACTIVITIES)?

PLEASE PLACE AN [ X ] NEXT TO ANY CONDITIONS YOU ARE CURRENTLY SUFFERING FROM AND A [ ● ] NEXT TO ANY CONDITIONS YOU HAVE HAD IN THE PAST .

GENERAL GASTROINTESTINAL GENITOURINARY

Headaches

Belching / Gas

Frequent Urination

Migraine Headaches

Constipation

Lack of Bladder Control

Allergies

Diarrhea

Kidney Problems

Sleep Difficulties

Allergies

Excessive Hunger / Thirst

Painful Urination

Jaw Problems

Poor Appetite

Discolored Urine

Bruise Easily

Abdominal Pains / Cramps

Prostate problems

Fatigue

Persistent Nausea

Depression

Gall Bladder Problems MALE / FEMALE

Anxiety

Hemorrhoids

Menstrual Irregularity

Nausea

Menstrual Cramping

Eating Disorder

Vomiting

Vaginal Pain / Infection

Learning Disability

Heartburn / Reflux

Breast pain / Lumps

Attention Deficit

Black / Bloody Stools

Sexual Dysfunction

Cancer

Loose Stools

Diabetes

Gall Bladder Problems FEMALE ONLY

Osteoporosis

Colitis When was your last period?

Digestive Problems Are you pregnant?

MUSCLES & JOINTS

Loss of Bowel Control

Yes

Not Sure

Neck Pain

Pain Between Shoulders CARDIOVASCULAR

Neck Pain

Low Back Pain

Chest Pain

Joint Pain / Stiffness

Shortness of Breath

Arthritis

Blood Pressure Problems

Muscle Tightness

Heart Problems

Difficulties Walking

Heart Attack

Carpal Tunnel

Stroke / TIA

Nervous System

Swollen Ankles

Numbness / Tingling

Bleeding Problems

Weakness

Dizziness RESPIRATORY

Paralysis

Lung Problems

Fainting

Asthma

Ringing In Ears

Difficulty Breathing

Convulsions/ Epilepsy

Cough

Loss of Balance

Spitting Blood

Seizures

I HEREBY CERTIFY THAT ALL ANSWERS AND INFORMATION PROVIDED ON THESE FORMS IS ACCURATE TO THE BEST OF MY KNOWLEDGE . I ALSO UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES IN MY HEALTH .

Patient Signature

PRINTED NAME:
DATE:

Patient Specific Functional Scale

WE WANT TO KNOW WHAT SORTS OF ACTIVITIES IN YOUR LIFE YOU ARE UNABLE TO PERFORM OR ARE HAVING THE MOST DIFFICULTY WITH AS A RESULT OF YOUR PROBLEM.

INSTRUCTIONS:

PLEASE LIST UP TO 3 ACTIVITIES BELOW THAT YOU ARE CURRENTLY UNABLE TO PERFORM OR ARE HAVING THE MOST DIFFICULTY WITH AS A RESULT OF YOUR PROBLEM.

PLEASE THEN RATE YOUR CURRENT ABILITY TO PERFORM THOSE ACTIVITIES BY CIRCLING THE NUMBER THAT BEST REPRESENTS YOUR ABILITY TO ENGAGE IN THAT ACTIVITY.

ACTIVITY # 1:

ACTIVITY # 2:

ACTIVITY # 3:

I HEREBY CERTIFY THAT ALL ANSWERS AND INFORMATION PROVIDED ON THESE FORMS IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I ALSO UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES IN MY HEALTH.

PATIENT SIGNATURE:

PRINTED NAME:
DATE: