WINFIELD CHIROPRACTIC RELIEF & WELLNESS

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WINFIELD CHIROPRACTIC RELIEF & WELLNESS Patient Information & Forms 1913 E. 19 th Ave Winfield, KS 67156 Phone# 620-221-1990 Fax# 620-221-4523 Website: www.winfieldchiropractic.com Email: winfieldchipractic@gmail.com

1. WELLNESS / PREVENTION If you are here for WELLNESS / PREVENTION services, please check here: What are your HEALTH objectives? Name/Address/Phone of the last doctor who put you on a HEALTH DEVELOPMENT PRGRAM? Were you able to stay on the program? How long? What were your results? Were your results permanent? Are you HEALTHIER today than you were 5 years ago? If so, what did you do to IMPROVE your health? If not, why do you think your HEALTH declined? Will you be HEALTHIER 5 years from now than you are today? If so, what are you planning to do to IMPROVE your health and if not, what could you do to IMPROVE your health rather than have it continue to decline? What are your TOP 3 GOALS for your HEALTH 5 years from now? Please CIRCLE a box in each categrory the best describes you. Example OK energy from the Energy Levels category

2. LIFESTYLE HABITS / MEDICATIONS/ SUPPLEMENTS Activity Frequency per week Duration in Minutes Stretching Walking/Running Strength Training Other (Pilates, yoga, boxing etc.) Sports or Leisure Activities (golf, tennis, rollerblading etc.) How many hours of television do you watch a day? 0 1-2 3-5 > 5 How many hours per day do you ride in a car or other vehicle? 0 1-2 3-5 > 5 Have you ever used tobacco? Never Past Weekly Monthly Yearly How many servings of alcohol do you drink each week? 0 1-2 3-5 > 5 How many servings of coffee do you drink each week? 0 1-2 3-5 > 5 How many servings of soda do you drink each week? 0 1-2 3-5 > 5 Please mark an X where you believe your health is and an O where you would like to be. DO YOU HAVE ANY ALLERGIES TO MEDICATIONS? MEDICATION or SUPPLEMENT LOG List the type of medications or supplements you are taking now. Medication or Supplement Name Date started Dated Stopped Reason for use WINFIELD CHIROPRACTIC & REHAB CENTER 1913 E. 19 TH Ave. Winfield, Kansas 67156, Dr. Brad Swanson & Dr. Doug Swanson

3. FAMILY & SELF HISTORY (Indicate with the bold letter below) : Father, Mother, Brother, Sister, Uncle, Aunt, GM-grandmother, GF-grandfather, self) Cancer, type: Heart disease: Hypertension: Stroke: High Cholesterol: Diabetes: Weight Problems: Arthritis: Low Back pain: Headaches: PMS: Other: Is there any other family history we should know about? Yes If yes, please comment No Prior Injuries: No History of previous injury or pain. (Please indicate when and describe how the injury occurred.) Fall Injury Lifting Injury Work- Job Related Injury Bicycle Injury Pedestrian Injury Military Injury Car Accident Motorcycle Injury Previous Surgeries: No history of surgical procedure. (If any previous surgery, type and when.) Surgery Year Hernia Rib/Collar bone: Shoulder/Elbow/Wrist/Hand: Gallbladder/Stomach/Kidney: Disc surgery (neck or back): Spine Surgery (neck or back): Thigh/Knee/Ankle/Foot: Hip Replacement Heart: Cancer Other Fractures/Broken Bones: No History of fracture For fracture/broken bones indicate LEFT / RIGHT and when the fracture occurred.) WINFIELD CHIROPRACTIC & REHAB CENTER 1913 E. 19 th Ave. Winfield, Kansas 67156, Dr. Brad Swanson & Dr. Doug Swanson

4. REVIEW OF SYSTEMS Please check ( ) any symptoms you currently have, even if they do not seem relateded to your current problem: Headaches Pins and needles in legs Fainting Neck pain Pins and needles in arms Loss of smell Back Pain Loss of balance Dizziness Buzzing in ears Ringing in ears Nervousness Numbness in fingers Numbness in toes Loss of taste Stomach Upset Fatigue Depression Irritability Tension Sleeping problems Stiff Neck Cold Hands Cold Feet Diarrhea Constipation Fever Hot Flashes Cold Sweats Lights bother eyes Urinary Problem Heartburn Mood Swings Menstrual Pain Irregular Cycles Ulcers Sinus Problems Earaches Asthma Sore Throat Bronchitis High Blood Pressure Low Blood Pressure Chest Pain Shoulder Pain Arm Pain Knee Pain Foot Pain 5. FAMILY HEALTH PROFILE At our office we are not only interested in your health and wellbeing but also that of your family and loved ones. Please mention below any health conditions or concerns you may have about your: Children: Spouse: Mother: Father: Brother(s): Sister (s): Others: WINFIELD CHIROPRACTIC & REHAB CENTER 1913 E. 19 th Ave. Winfield, Kansas 67156, Dr. Brad Swanson & Dr. Doug Swanson

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