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Transcription:

Name: First Name Middle Initial Date: Last Name Mailing Address: City State Zip: Social Security #: Age: Sex: Male Female Height: Work Phone: ( Birth Date: Home Phone: ( Weight: Cell Phone: ( Email Address: Occupation: Employer Name & Address: Best Time to Contact: Status: Single Married Divorced Widowed Spouse Name: Cell Phone: ( Birth Date: Work Phone: ( Employer: Number of Children, Names and Ages: In case of emergency, please notify: Check any of the applicable options below: Workman s Compensation Claim Auto Insurance Claim Phone: ( Medicare Medicaid If you checked any of the above insurance options, please give your insurance information to the front desk. 1

YOUR HEALTH Please place an X on the scale above marking where you believe your current level of health and wellness is located; place a CIRCLE on the diagram indicating where you would like to be. 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 complaints and are here for Chiropractic Wellness Services, please skip the GENERAL HISTORY section below. We are excited to have you in our office. Describe concern and rate severity: 1 = Mild, 10 = Worst Imaginable Does this interfere with your: Work Leisure Sleep Sports Other: If you have seen other doctors for this condition, mark which you have consulted: Chiropractor Medical Doctor Other: Please mark you areas of concern on the figures below. GENERAL HISTORY List all medications (prescription & nonprescription that you are taking and why: List any vitamins or supplements that you are taking and why: 2

CHIROPRACTIC SYSTEMS REVIEW INSTRUCTIONS: Place an (X next to the systems that apply. Use the nerve chart as a visual reference tool. NECK The nerves of the neck innervate. Do you have difficulty now or in the past with SORE THROAT STIFF NECK RADIATING ARM PAIN DIZZINESS MUSCLE JERKING FAINTING HEADACHES CONVULSIONS FORGETFULNESS CONFUSION DEPRESSION HEAD COLDS HANDFINGER NUMBNESS HIGH BLOOD PRESSURE HEART CONDITIONS SINUS PROBLEMS ALLERGIES MIGRAINES HEARING PROBLEMS EAR NOICESRINGING CONCENTRATION PROBLEMS VISION PROBELMS NOSE BLEEDS SORE GUMS FATIGUE MIDBACK BACK The nerves of the mid back innervate. Do you have difficulty now or in the past with MIDDLE BACK PAIN LIVER TROUBLE GALL BLADDER TROUBLE CHEST PAIN PNEUMONIA KIDNEY PROBLEMS STONES BRONCHITIS RAPID HEARTBEAT VOMITING OR REFLUX ABDOMINAL PAIN NAUSEA CONGESTION ULCERS STOMACH PROBLEMS DIGESTION LOW BACK L The nerves of the low back innervate. Do you have difficulty now or in the past with BLADDER BOWEL PROBLEMS REPRODUCTIVESEXUAL PROBLEMS LEG NUMBNESS WEAKNESS EXCESS URINATION HEMORRHOIDS PMSFEMALE PROBLEMS LOWER BACK PAIN NOTES 3

List and date any surgeries, hospitalizations or traumatic injuries: On a scale of 1 10, rate your psychologicalemotional stress levels: (1 = None, 10 = Extreme Occupational: Personal: On a scale of 1 10, describe the following: (1 = Poor, 10 = Excellent Eating Habits: Energy: Exercise Habits: General Health: Mindset: Sleep: At All About Potential, we are concerned with your health and wellness goals. Please list all of your goals for your health and wellness in the space provided. Check all that apply: I have purchased bottled water. I have belonged to a health club. I have consumed vitamins or supplements. If there is a need for dietary changes, I would like to know. If there is a need for specific exercises, I would like to know. If there is a need for support in the psychologicalmindbodystress dimension of my health, I would like assistance. I acknowledge that the above information is accurate and true. PATIENTGUARDIAN SIGNATURE DATE Thank you for filling out this form. It is your first step to health! Return this to our staff and someone will be right with you. 4

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