Personal Information

EMERGENCY CONTACT INFORMATION

IS CONDITION:







Current Health Condition

































































Previous Chiropractic Care






Past Health History













Social History & Habits







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

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 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.







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.