Name
*
Age
Date
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
# of Children
Occupation
Employer
Phone (Work)
Insured's Name
Phone Number
Insured's Date of Birth:
/
Month
/
Day
Year
Date
Spouse's Name
Spouse's Telephone (Cell)
Past Chiropractic Care?
Yes
No
When?
Doctor's Name
Results
Referred by
Insurance Company
*
Telephone
Social Security Number
Emergency Contact
Relationship
Contact Number
Are your present problems due to an occupational injury or a motor vehicle accident?
Yes
No
Has the accident been reported?
Yes
No
Have you retained an attorney?
Yes
No
Are you now or have you ever been disabled? (Service or work)
Yes
No
Smoking
No
Yes
Alcohol
No
Yes
Caffeine
No
Yes
Exercise
None
Light Activity
Moderate Activity
Active
Very Active
Elite Athlete
Family History
Mother
Diabetes
Heart
Kidney
Cancer
Other
Father
Diabetes
Heart
Kidney
Cancer
Other
Have you had, or do you have any of the following conditions?
Anemia
Heart Disease
Arthritis
Pneumonia
Goiter
Eplilepsy
Mental Disorder
Polio
Pleurisy
Tuberculosis
Diabetes
Alcoholism
Cancer
HIV Positive
Migraine Headaches
Multiple Sclerosis
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Pain Symptoms
In order of severity
Symptom 1
*
When did it begin? (Month/Year)
Previous episodes
Symptom 2
When did it begin? (Month/Year)
Previous episodes
Symptom 3
When did it begin? (Month/Year)
Previous episodes
What is your pain right now?
*
0
1
2
3
4
5
6
7
8
9
10
No pain
Worst possible pain
0 is No pain, 10 is Worst possible pain
What is your typical or average pain?
*
0
1
2
3
4
5
6
7
8
9
10
No pain
Worst possible pain
0 is No pain, 10 is Worst possible pain
What is your pain level at its best (How close to "0" does your pain get at its best)?
0
1
2
3
4
5
6
7
8
9
10
No pain
Worst possible pain
0 is No pain, 10 is Worst possible pain
What is your pain level at its worst (How close to "10" does your pain get at its worst)?
0
1
2
3
4
5
6
7
8
9
10
No pain
Worst possible pain
0 is No pain, 10 is Worst possible pain
Other comments:
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General Symptoms
Allergy
Previously
Presently
If you have an allergy, what are you allergic to?
Convulsions
Previously
Presently
Dizziness
Previously
Presently
Fainting
Previously
Presently
Fatigue
Previously
Presently
Headache
Previously
Presently
Loss of Sleep
Previously
Presently
Loss of Weight
Previously
Presently
Nervousness
Previously
Presently
Neuralgia
Previously
Presently
Sweats
Previously
Presently
Depression
Previously
Presently
Gastrointestinal
Belching/Gas/Bloating
Previously
Presently
Abdominal Pain
Previously
Presently
Constipation
Previously
Presently
Diarrhea
Previously
Presently
Gallbladder Trouble
Previously
Presently
Jaundice
Previously
Presently
Liver Trouble
Previously
Presently
Nausea
Previously
Presently
Stomach Pain
Previously
Presently
Poor Appetite
Previously
Presently
Poor Digestion
Previously
Presently
Excessive Thirst
Previously
Presently
Indigestion
Previously
Presently
Rectal Bleeding
Previously
Presently
Eye/Ears/Nose/Throat
Asthma
Previously
Presently
Deafness
Previously
Presently
Tinnitus
Previously
Presently
Enlarged Thyroid
Previously
Presently
Hay Fever
Previously
Presently
Hoarseness
Previously
Presently
Nasal Obstruction
Previously
Presently
Nosebleeds
Previously
Presently
Poor Vision
Previously
Presently
Sinusitis
Previously
Presently
Tonsilitis
Previously
Presently
Persistent Cough
Previously
Presently
Difficulty Swallowing
Previously
Presently
Respiratory
Chest Pain
Previously
Presently
Chronic Cough
Previously
Presently
Difficulty Breathing
Previously
Presently
Genito-Urinary
Blood in Urine
Previously
Presently
Frequent Urination
Previously
Presently
Lack of Bladder Control
Previously
Presently
Kidney Infection
Previously
Presently
Painful Urination
Previously
Presently
Prostate Trouble
Previously
Presently
Muscles/Joint/Bones
Backache
Previously
Presently
Foot Trouble
Previously
Presently
Hernia
Previously
Presently
Pain Between Shoulders
Previously
Presently
Painful Tailbone
Previously
Presently
Stiff Neck
Previously
Presently
Spinal Curvature
Previously
Presently
Swollen Joints
Previously
Presently
Tremors/Twitching
Previously
Presently
Arm Trouble
Previously
Presently
Cardio-Vascular
High Blood Pressure
Previously
Presently
Low Blood Pressure
Previously
Presently
Pain Over Heart
Previously
Presently
Poor Circulation
Previously
Presently
Previous Heart Trouble
Previously
Presently
Rapid Heart
Previously
Presently
Slow Heart
Previously
Presently
Strokes
Previously
Presently
Swelling Ankles
Previously
Presently
Varicose Veins
Previously
Presently
For Women Only
Cramps or Backaches
Previously
Presently
Hot Flashes
Previously
Presently
Irregular Cycle
Previously
Presently
Painful Periods
Previously
Presently
Lump in Breast
Previously
Presently
Pregnant at this time?
Yes
No
Have you had a mammogram?
Yes
No
Last Pap Smear Date
By whom?
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Operations & Procedures
Vaccinations
Date
Tonsillectomy
Date
Gallbladder
Date
Back Operation
Date
Tubes in Ears
Date
Appendectomy
Date
Female Organs
Date
Rectal Surgery
Date
Sinus
Date
Hernia
Date
Thyroid
Date
Stomach
Date
Other
List any accidents or falls:
Car
Recreation
Sports
School
Other
List the dates of any accidents or falls:
List any broken bones (fractures) or dislocations:
Ever on crutches?
Yes
No
If yes, why?
Were you ever knocked unconscious?
Yes
No
Have you ever had any spinal taps or spinal injections?
Yes
No
Have you ever had a lapse of memory?
Yes
No
Have you ever had X-rays taken?
Yes
No
If yes, when? and by whom? For what ailments were these X-rays made?
Do you suffer from any condition other than that for which you are now consulting us?
Are you presently taking any medication - prescription or over-the-counter?
*
Yes
No
What drugs?
Signature
*
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