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NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children : Employee Name and Address: Marital Status: Names and Ages: PERSONAL INFORMATION: As a society we are 50th in the world in health care. We take pride in helping people attain their optimum health and wellness. With that being said we need an honest assessment of your current level of health. So please place an X on the scale below, indicating your level of health and wellness at this time. Then place a star (*) on the diagram, showing us the desired location of your health and wellness. Very challenged Challenged Transition Good Excellent 0-50 50-75 75-100 100-125 125+ YOUR HEALTH PROFILE:

What brings you into our office? Please briefly describe your chief concern, including the impact it has had on your life. If you have no symptoms or concerns right now and you are here for Chiropractic Wellness Services please skip to the General History page. Health Concerns: Severity 1 = mid 10 = worst imaginable When did this start? Are symptoms constant or intermittent? Did the problem begin with an injury? Since the challenge started, it is: The Same Getting Better Getting Worse What makes it worse? What, if anything makes it feel better? This interferes with your: Work Leisure Sleep Sports Other: It s common for people to have multiple doctors on their health care team. Which doctors have you seen for your challenges? Chiropractor Medical Other (Please List): During the above visits was the cause of your health challenge identified? Yes No If yes, what was the diagnosis? What was the recommended solution? GENERAL HISTORY: Given that prescription medications are in the top 5 leading causes of preventable death in the United States we are interested in knowing what, if any, medications you take and why:

It is becoming more popular for people to take charge of their own health and wellbeing. Supplementation is a major trend in this movement. Please list any supplements or vitamins that you are taking and why: Have you had any surgeries or hospitalizations? (Please include all surgeries) Have you ever had any work related injuries? Slips and falls, although common have a direct impact on your health and wellbeing. Even MINOR falls or accidents cause stress, strain and damage to the spine that take up to 18 months to heal. If you have had any slips, falls or auto accidents (even minor) please list them here: Since the Nervous System controls everything in your body it is quite likely that your current health challenges are related to the problems you are seeking care for in our office. Please check ( ) the following symptoms you have had, whether CURRENT (C) or PAST (P): Past Current Headaches Loss of smell Loss of taste Ulcers Fatigue Cold Hands Headaches Diarrhea Cold Sweats Fainting Back pain Nervousness Stomach upset Depression Cold feet Fever Menstrual Pain Heartburn Past Current Neck stiff/pain Loss balance Tension Dizziness Irritability Constipation Hot flashes Urinary issues Asthma

Arm tingling Buzz/ring in ears Numbness in fingers Numbness in toes Sleeping problems Lights bother eyes Menstrual irregularity Tingling in legs Allergies If we have not listed current health challenges on the list above please now list additional health concerns in the lines below: thanks for providing us with pivotal information that can literally change your life! On to the next page!!! It has been shown that daily lifestyle stress significantly impacts overall health and wellbeing. As a family wellness office we specialize in removing the cause of your health challenges. We also focus on teaching you how to manage the lifestyle stresses that prevent you from realizing your optimum health and wellness. Please rate the following and circle ALL answers that apply to your habits: (1 being very poor and 10 being excellent) Eating habits: Exercise habits: a. I eat 3-5x s a day a. I exercise 3-5 times a week. b. I eat fruits and vegetables daily. b. I walk daily. c. I eat out 2-3 times weekly (min) c. I don t exercise. d. I drink 3-5 sodas weekly d. I want to exercise. e. I crave sweets. e. I sit at computer 6-8 hours/day f. I don t watch what I eat. Sleep: Mind Set: a. I sleep 7-9 hours/night a. I have a positive outlook. b. I wake up well rested b. I have a negative outlook. c. I wake up tired. c. I am always in a bad mood. d. I toss and turn. d. I am always in a good mood. e. I stay up late. e. I trap things inside. f. I share easily. General Health: a. I am not on medications. b. I take care of myself.

c. I watch what I eat. d. I base my health on how everyone around me is doing. e. I think I am healthy but know I could make some changes. On a scale of 1-10 describe your psychological/emotional stress levels: (1= none/ 10=extreme) Occupational: Personal: You are almost there! Thanks for providing us with information that could help us to better serve you and help you to be the best you can be! YOUR GOALS At our office we pride ourselves in helping you to achieve phenomenal results with your health and wellness. So that we can help you achieve your optimum health it is important that we understand your goals for your overall health and wellbeing. Please list your goals for your health and wellness in the spaces provided. Physical Goals Nutritional/Biochemical Goals Psychological Goals If there is a need for dietary changes would you like to know? If there is a need for specific exercises would you like to know? If there is a need for support in the psychological, mind-body or stress management dimensions of health would you like assistance? YOU ARE ALMOST THERE! HAVE YOU EVER:

Bought bottled water: Belonged to a health club: Consumed vitamins or supplements Eaten organic foods? Started a diet program? Gotten more than 6 massages in a year? Now we just need your permission to continue through our process! I consent to a professional and complete chiropractic examination and to any radiographic examination that the doctor deems necessary. I understand that any fee for service rendered is due at the time of service and cannot be deferred to a later date. Signature Date: Thank you for filling out this form. It is your first step to Creating Wellness! Present this to our staff and in a moment we will be starting our journey together!

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