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Vitality Chiropractic & Wellness Center 3348 Tyrone Blvd. St. Petersburg, FL 33710 WWW.DrWyckoff.com Phone (727) 381-7433 Fax (727) 381-7434 Welcome to our office! Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don t hesitate to ask one of our qualified Chiropractic Assistants. It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care.

HEALTH CONCERNS: Please list your top health concerns in order of priority. 1) 2) 3) 4) TREATMENT: What type of treatment are you looking for? I am looking for the most minimal amount of care to patch up the symptoms of my problem. I am looking to resolve my symptoms and then go on to fix the cause of my problem. I am looking to take care of my problem and then go on to achieve optimal health and wellness. Please mark on the diagram to the right the following symbols as they relate to the patients symptoms: SS = spasms DP = dull pain SH = shooting pain NU = numbness ST = stiffness SP = sharp pain TI = tingling O = Other COMPLAINT/PROBLEM: In relation to your primary complaint: When did you first seek treatment for this problem? Has another doctor(s) treated you for this condition: Y N Whom? MD DO DC DDS Other: Name of primary doctor? Treatment(s) Tried: Medication Surgery Lifestyle change Chiropractic other Have you had any intolerance or reactions to treatments? Y N Describe: When did the problem start?: How did it originally occur? Has it become worse recently? Y N Same Better Gradually worse How frequent is the condition? Constant Daily Intermittent How long does it last? All day Few hours Minutes Is this condition interfering with your? Work Sleep Daily routine Recreation Does anything relieve the symptom(s)? Y N Medication(prescription or OTC) Rest Exercise/Stretch Other: If no, what have you tried? Medication (prescription or OTC) Rest Exercise/Stretch Surgery Is there anything that you can do to relieve the symptom? Y N Medication(prescription or OTC) Rest Exercise/Stretch Other: If no, what have you tried to do that has not helped? Medication (prescription or OTC) Rest Exercise/Stretch Surgery Chiropractic Other: How long has it been since you really felt good? Days Weeks Months Years >10 years Describe the pain/problem: Sharp Dull Numbness Tingling Aching Burning Stabbing Other: What makes the problem worse? Standing Sitting Lying Bending Lifting Twisting Other: What do you believe is cause of the problem? Are there any other conditions or symptoms that may be related to your major symptom? Y N If yes, what? Please check all of the symptoms that apply. (P=Past / C= Current) P / C P / C P / C P / C P / C Headache High Blood Pressure Tingling in Feet Facial Pain ` Low Blood Pressure Walking Problems Eye Pain Abdominal Pains Sore Muscles Blurred Vision Nausea/Vomiting Weak Muscles Dizziness Poor Appetite Paralysis Earache Fullness of Bladder Shakiness Forgetfulness Urination Difficulty Sweating Confusion Frequent Urination Insomnia Sinusitis Constipation Fainting Teeth Grinding Hemorrhoids Convulsions Dry Mouth Decreased Sex Drive Irritability Excessive Thirst Menstrual Irregularities Impatience Unpleasant Taste Elbow / Hand Pain Fatigue Neck Pain Tingling in Hands Feel Loss of Control Sore Throat Clammy Hands Lump in Throat Low Back Pain Swallowing Pain Hip Pain Unsteady Voice Knee Pain Shoulder Pain Poor Circulation Persistent Coughing Swollen Joints Chest Pressure Joint Stiffness Slow Heart Rate Swollen Ankles Rapid Heart Rate Ankle / Foot Pain Other:

ALLERGIES/Sensitivities: Please check and list all allergies. Food: Dairy Wheat Corn Soy Seafood Gluten Peanuts Fruits Other: Medications: Penicillin Sulfa Drugs Iodine Insulin Antibiotics Other: Seasonal/Other: Pollen Dust Hay Mold Chemical(s) Smoke Animals Insects Other: MEDICATIONS: Please check and list all medications that you are currently taking with the date you began taking them. Medication Name Date Started Antacids Antibiotics Antidepressants Anti-Diabetics Anti-Inflammatory Blood Pressure Lowering Meds. Cholesterol Lowering Meds. Hormone Replacements (HRT) Oral Contraceptives OTC (over the counter) Other SUPPLEMENTS: Do you take Vitamins/Supplements or Herbs? Y N If yes, who recommended them? SCARS / SURGICAL PROCEDURES: Have you had any surgical procedures? YES NO Any Scars? YES NO SPINE: Cervical Thoracic Lumbar EXTREMITIES: Shoulder/Elbow/Hand/Wrist R L Hip/Knee/Ankle/Foot R L ABDOMINAL/CHEST: Appendix Colon Gall Bladder Heart Lungs Breast Other: HABITS: Heavy Moderate Light None 5-7x/wk 3-5x/wk 1-3x/wk None Type Alcohol Exercise Aerobic Weights. Coffee 8+ hrs 7-8 hrs 6-7 hrs 5-6 hrs <5 hrs Soda / Diet Soda Sleep. Tobacco 5+ 4 3 2 Drugs Meals / day. Stress Level 64+ oz 32-64 oz 16-32 oz <8 oz Water / day WORK ACTIVITY: Heavy Labor Light Labor Mostly Sitting Mostly Standing Walking / Moving Driving FAMILY HISTORY: Identify any conditions that you, or any of your family members have now or have had in the past: (F = Family, P = Personal History) Alcoholism Eczema Miscarriage(s) Tumor(s) Anemia Emphysema Mumps Ulcer(s) Cancer Epilepsy Pleurisy Other: Cold sores Goiter Pneumonia Deep vein thrombosis Gout Polio Detached retina Heart disease Rheumatic fever Diabetes HIV / AIDS Stroke Patient s Printed Name Patient s Signature Date Reviewed By: Date:

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