Patient Information: Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Email: Home # Cell # Work # Text Appointment Reminders: Yes No (If you choose yes, one text message will be sent to you the day of your appointment) Address City State Zip Emergency Contact Emergency Relation Emergency Phone Employer Information: Employed: Yes No Retired: Yes No Employer Name: Occupation: Work Duties: Referral Information: Did someone refer you to our office? Referring Physician: Referring Patient: Other: How did you hear about us? Google Facebook Yahoo Health Grades Chiropractor Near Me Sign Drive By Yellow Pages Mailing Other Chiropractic Experience: Have you ever been seen by a Chiropractor? Yes No If yes, Why? Doctor s Name: Approximate Date of Last Visit:
Reason for this Visit: Describe the reason for your visit? When did this concern begin? Injury Occurred: Work Automobile Other Has this concern occurred before? Yes No Explain: Have you seen other doctors for this concern? Yes No Doctor s Name: Type of Treatment: Where is your Pain/Discomfort? Neck Upper Back Mid Back Lower Back Right Shoulder Right Arm Right Elbow Right Hand Left Shoulder Left Arm Left Elbow Left Hand Right Thigh Right Knee Right Leg Right Foot Left Thigh Left Knee Left Leg Left Foot On a scale from 1 to 10, what would you rate your pain right now? 1 2 3 4 5 6 7 8 9 10 How much of the day is the pain/discomfort present? 25% of the day 50% of the day 75% of the day 100% of the day On a scale from 1 to 10, rate your worst pain/discomfort during this episode: 1 2 3 4 5 6 7 8 9 10 On a scale from 1 to 10, rate your least pain/discomfort during this episode: 1 2 3 4 5 6 7 8 9 10 Did this pain or discomfort begin: Suddenly Gradually Since the pain or discomfort has begun, has it gotten: Worse Better Same What aggravates this? Working Lifting Walking Running Driving Sitting Standing Bending Kneeling Changing Positions Dressing Exercising Sleeping Turning/Twisting Reaching Using Computer Other What relieves this pain or discomfort? Nothing Rest Sleeping Sitting Walking Standing Stretching Aspirin Acetaminophen (Tylenol) Ibuprofen (Motrin) Ice Heat Biofreeze/Icy Hot Other
Reason for this Visit (continued): How would you describe your pain/discomfort? Mild Moderate Severe Aching Burning Dull Numbness Sharp Throbbing Tingling Stiff Other When is the pain or discomfort the worst? Morning Afternoon Evening Does the pain or discomfort travel somewhere else? Yes No If Yes, where does the pain stop at? Explain: If numbness/tingling is present, where? Explain: Does any part of your body feel like it is falling asleep? If so, where? For Women Only: Are you pregnant? Yes No Chance Pregnant? Yes No Are you nursing? Yes No Planning? Yes No Personal Incident History: Broken Bones: Yes No Explain: Sprains/Strains: Yes No Explain: Hospitalized: Yes No Explain: Surgery: Yes No Explain: Auto Accident: Yes No Explain: Stroke: Yes No Explain: Personal Health History: Last Physical Exam: Primary Physician: Physician Phone #: Health Conditions: Medications:
FAMILY HEALTH HISTORY Patient Name Date Please review the below listed symptoms and conditions and indicate those that are current health problems of a family member by the designation C under his/her column. The designation P should be used to indicate a past problem. Leave blank those spaces that do not apply. Father Mother Spouse Brother(s) Sister(s) Children Condition Allergies Arm Pain Arthritis Auto Accidents Back Pain Cancer Diabetes Digestive Issues Disc Bulge/Herniation Fibromyalgia Frequent Colds/Flus Headache Heartburn Heart Trouble High Blood Pressure Hip Pain Knee Pain Leg Pain Low Energy Migraines Neck Pain Numbness/Tingling Pinched Nerve Sciatica Scoliosis Shoulder Pain Sinus Trouble Slipped Disc TMJ Pain Other:
Personal Health Checklist: Allergies AIDS Anemia Arteriosclerosis Arthritis Asthma Back Pain Breast Lump Bronchitis Bruise Easily Cancer Chest Pain Cold Extremities Constipation Cramps Depression Diabetes Digestion Problems Dizziness Eye Pain/Difficulties Fatigue Excessive Menstruation Frequent Urination Headache Hemorrhoids Venereal Disease Hot Flashes Irregular Heart Beat Irregular Menstrual Kidney Infection Kidney Stones Loss of Memory Loss of Balance Loss of Smell Loss of Taste Nosebleeds Pacemaker Polio Poor Posture Prostate Trouble Sciatica Shortness of Breath High Blood Pressure Sinus Infection Insomnia Spinal Curvatures Stroke Swelling of Ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Other Goals for Your Care: People see a Chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible. I want the Doctor to select the type of care appropriate for my condition. Relief Care: Symptomatic relief of pain or discomfort Corrective Care: Correcting and relieving the cause of the problem as well as the symptom Comprehensive Care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care. Were you aware that: Chiropractic is the largest natural healing profession in the world? Yes No Doctors of Chiropractic work with the nervous system? Yes No The nervous system controls all bodily functions and systems? Yes No Patient Name: Patient/Guardian Signature: Date: