M A R T IN C H IR OPR A C T I C K IN E T I C SPO R TS M E DI C IN E Patient Contact Information: NAME Email Address DRIVERS LICENSE # Street Address City State Zip Home Phone Best Time Call Work Phone Best Time Call Date of Birth Age Weight Height Gender Primary Physician (name, address and phone number) How did you hear about us? PRIMARY INSURANCE CARRIER COMPANY NAME OF INSURED BILLING ADDRESS CITY STATE ZIP PHONE MEMBER#
SECONDARY INSURANCE COMPANY INSURED BILLING ADDRESS CITY STATE ZIP PHONE MEMBER# PATIENT EMPLOYMENT INFORMATION EMPLOYER ADDRESS CITY STATE ZIP PHONE OCCUPATION LENGTH SPOUSE/EMERGENCY CONTACT NAME DATE OF BIRTH OCCUPATION Patient Family Medical History: Please check off if anyone in your family has had problems with: Diabetes, Thyroid or other Hypertension Cardiovascular Disease Cancer Endocrine Disorders Lipid Disorder Prostate Disease Other Illness not noted Patient Medical History: Please check off if you have a history or early finding of the following: Pregnant/Lactating Cancer Poor wound healing Blood Disorders Immune Disorders Edema/excess fluid retention
High Cholesterol Lung Disorder Renal Disease Emotional Disorders Glaucoma Surgery Chemical Dependency Upper respiratory problems High Blood Pressure Heart Attack Genital-Urinary Disorder Carpal Tunnel Syndrome Drug Allergies Food Allergies Neurological disorders, Thyroid, Diabetes or other endocrine disorder including insulin resistance, or diabetes Any known deficiency including minerals and electrolytes Orthopedic or muscle disorder including fracture or joint disorders Heart disease including Atherosclerosis, Angina, or Heart Failure Any other illness not noted If you checked off any item above, please explain; Are you pregnant? Yes/No Last day of menstrual cycle? Do you get regular exercise? If yes, what type, frequency, duration, & where? Medications used in the past 12 months? If yes, please list Previous weight loss? If yes, explain if recent or long term history
When was the last time you were sick? Questions for determining factors for treatment of your medical condition: Please check off if you have had any of the following: Loss of concentration, sociability, activity Increasing mood swings Increasingly stressed Decreasing memory / Short term Long term Decreased desire and ability to exercise Decreased sense of well-being Depression Decreasing size of testicles Urogenital atrophy Cold or heat intolerance Increasing wrinkles Increase sagging muscles or breasts endurance Muscle loss Difficulty sleeping Increase in lack of drive Less interest in sex Vaginal dryness Hot flashes Thinning of loss of hair Sagging, loose or thin skin Decreased energy or Decreased muscle strength Progressive osteoporosis, decreasing bone mass or stooped posture Increasing fat deposits about the abdomen or thighs Restless leg syndrome How many caffeinated drinks (daily)? How many energy drinks (daily)?
C O N F ID E N T I A L H E A L T H Q U EST I O N A IR E NAME AGE DATE CHECK CONDITIONS THAT APPLY GENERAL ALLERGY FATIGUE CONSTIPATION DIARRHEA NAUSEA VOMITTING DIZZINESS PAINFUL BREATHING ASTHMA HIGH/LOW BLOOD PRESSURE FREQUENT URINATION PAINFUL URINATION PROSTATE TROUBLE MUSCLE/JOINTS WOMEN ONLY HEADACHES CRAMPS/ BACKACHE NECK PAIN/STIIFNESS EXCESS MENSTRUAL FLOW SHOULDER PAIN HOT FLASHES ARM PAIN, NUMB IRREGULAR CYCLE ELBOW PAIN LUMPS IN BREAST WRIST/HAND PAIN PARI/PRE-MENOPAUSE MID BACK PAIN MENOPAUSE LOW BACK PAIN MISCARRIAGE HIP PAIN PAINFUL MENSTRATION SCIATICA KNEE PAIN LEG PAIN/NUMBNESS ANKLE/FOOT PAIN, NUMBNESS ARTHRITIS- TYPE OTHER CONDITIONS THAT YOU HAVE OR HAVE HAD ALCOHOLISM ANEMIA ARTHROSCLEROSIS CANCER EMPHYSEMA EPISEPSY GOUT HEART DISEASE PACEMAKER PNEUMONIA STROKE MULTIPLE SCLEROSIS
REASON FOR VISIT HOW LONG HAVE YOU HAD THIS CONDITION? GETTING WORSE/BETTER DO YOU HAVE PAIN DURING AM PM WORK HOME SLEEP RISING ACTIVITY INITIAL CAUSE OF PAIN? PREVIOUS MEDICAL OR CHIROPRACTIC HISTORY DATE OF LAST VISIT DOCTOR NAME M E DI C A L H IST O R Y BROKEN BONES HOSPITALIZATION SURGERIES SPRAINS/STRAINS DRUG ALLERGIES LIST OF OTHER MEDICAL CONDITIONS EXERCISE YES/ NO DAYS PER WEEK OTHER ACTIVITIES NOTES
Please list your desired fitness goals: Desired Body Fat: % Desired Weight: (lbs) How many times a week do you plan on exercising? Please check the equipment that you have access to: Free Weights Machines Swiss/Exercise Ball Medicine Ball Balance Board Slant Bench Cables Aerobics Step Balance Disk Elastic Tubing/Bands