• Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Marital Status
  • Insured's Date of Birth:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Past Chiropractic Care?
  • Are your present problems due to an occupational injury or a motor vehicle accident?
  • Has the accident been reported?
  • Have you retained an attorney?
  • Are you now or have you ever been disabled? (Service or work)
  • Smoking
  • Alcohol
  • Caffeine
  • Exercise

  • Family History

  • Mother

  • Father

  • Have you had, or do you have any of the following conditions?

  • Complaints

    In order of severity
  •    
  •    

  • General Symptoms

  • Allergy
  • Convulsions
  • Dizziness
  • Fainting
  • Fatigue
  • Headache
  • Loss of Sleep
  • Loss of Weight
  • Nervousness
  • Neuralgia
  • Sweats
  • Depression

  • Gastrointestinal

  • Belching/Gas/Bloating
  • Abdominal Pain
  • Constipation
  • Diarrhea
  • Gallbladder Trouble
  • Liver Trouble
  • Nausea
  • Stomach Pain
  • Poor Appetite
  • Poor Digestion
  • Excessive Thirst
  • Indigestion
  • Rectal Bleeding

  • Eye/Ears/Nose/Throat

  • Asthma
  • Deafness
  • Tinnitus
  • Enlarged Thyroid
  • Hoarseness
  • Nasal Obstruction
  • Nosebleeds
  • Poor Vision
  • Sinusitis
  • Tonsilitis
  • Persistent Cough
  • Difficulty Swallowing

  • Respiratory

  • Chest Pain
  • Chronic Cough
  • Difficulty Breathing

  • Genito-Urinary

  • Blood in Urine
  • Frequent Urination
  • Lack of Bladder Control
  • Kidney Infection
  • Painful Urination
  • Prostate Trouble

  • Muscles/Joint/Bones

  • Backache
  • Foot Trouble
  • Hernia
  • Pain Between Shoulders
  • Painful Tailbone
  • Stiff Neck
  • Swollen Joints
  • Tremors/Twitching
  • Arm Trouble

  • Cardio-Vascular

  • High Blood Pressure
  • Low Blood Pressure
  • Poor Circulation
  • Previous Heart Trouble
  • Strokes
  • Swelling Ankles

  • For Women Only

  • Pregnant at this time?

  • Operations & Procedures

  • Have you ever had any spinal taps or spinal injections?
  • Were you ever knocked unconscious?
  • Have you ever had a lapse of memory?
  • Have you ever had X-rays taken?
  • Are you presently taking any medication - prescription or over-the-counter?*
  • Should be Empty: