CONFIDENTIAL PATIENT INFORMATION

Date

Full Name:

DOB:

Sex:

Male Female

Marital Status:

# of Children:

Occupation:

Street Address:

City:

State/Province:

Postal/Zip Code:

Height:

Weight:

Email:

Cell Phone:

Other Phone:

Emergency Contact:

Emergency Relation:

Emergency Phone:

How did you here about us?

Who is your primary care physician

Date and reason for your last doctor visit:

Are you also receiving care from any other health professional?

Yes No

If yes, please name them and their specialty:

please note any significant family medical history:

What health condition(s) bring you into our office?

Have you received care for this problem before?

Yes No

If yes, please explain:

When did the condition(s) first begin?

How did the problem start?

Suddenly Gradually Post-Injury

Is this condition:

Getting worse Improving Intermittent Constant Unsure

What makes the problem better?

What makes the problem worse?

Please indicate where you are experiencing pain or discomfort

Mark the areas on the image where you are experiencing symptoms

Your top three health goals:

CHIROPRACTIC HISTORY

What would you like to gain from chiropractic care?

Resolve existing conditions Overall wellness Both

Have you ever visited a chiroprctic?

Yes No

If yes, what is their name?

What is their specialty?

Pain Relief Physical Therapy & Rehab Nutritional Subluxation-based

Other

Do you have any heath concerns for other family member today?

TRAUMAS: Physical Injury History

Have you ever had any significant falls, surgeries or other injuries as an adults?

Yes No

If yes, please explain:

Notable childhood injuries

Yes No

If yes, please explain:

Youth or college sports?

Yes No

If yes, list major injuries:

Any auto accident?

Yes No

If yes, please explain:

Exercise frequency?

None 1-2x per week 3-6x per week Daily

What type of exercise?

How do you normally sleep?

Back Side Stomach

Do you wake up:

Refreshed and ready Stiff and tired

Do you commute to work?

Yes No

If yes, how many minutes per day?

List any problem with flexibly. (ex. Putting shoes/socks, etc.)

How many hours per day you typically spend sitting at a desk or on a computer, table or laptop?

Toxins: Chemical & Environmental Exposure

Please rate your CONSUMPTION for each :

Alcohol