PATIENT INFORMATION
Today's Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Middle Initial
Nickname
Phone
*
Format: (000) 000-0000.
Address
*
City
*
State
*
Zip
*
E-mail
*
example@example.com
Birthdate
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
*
Marriage Status
*
Employer/School
Occupation
Emergency Contact
Name
*
Relationship to Patient
Phone
*
Format: (000) 000-0000.
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PATIENT CONDITION
Reason for Visit
When did symptoms appear?
Where is there pain, numbness, or tingling?
Right Shoulder
Left Shoulder
Neck
Mid Back
Low Back
Right Hip
Left Hip
Right Arm
Left Arm
Right Leg
Left Leg
Right Foot
Left Foot
Right Hand
Left Hand
Head
Rate the severity of your pain between 0-10.
0=no pain, 10=take me to the hospital
Type of pain
Sharp
Aching
Throbbing
Shooting
Numbness
Burning
Tingling
Spasm
Other
Stiffness
Is pain constant or intermittent?
Does it interfere with your
Work
Recreation
Sleep
Daily Routine
Activity that is painful to perform
Sitting
Standing
Walking
Lying Down
Bending
What treatment have you already received for your condition?
Medications
Surgery
Physical Therapy
Chiropractic Services
None
Other
Other doctors who have treated you for your condition?
Date of Last Relevant:
Physical Exam
Spinal Exam
Chest X Ray
Spinal X Ray
MRI, Bone, or CT Scan
Are you pregnant?
Yes
No
If so, due date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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HEALTH HISTORY
Place a mark on "Yes" or "No" to indicate if you have had any of the following:
Rows
Yes
No
AIDS/HIV
Alcoholism
Allergy Shots
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorders
Breast Lump
Bronchitis
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Diabetes
Emphysema
Epilepsy
Fractures
Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herniated Disk
Herpes
High Cholesterol
Kidney Disease
Liver Disease
Measles
Migraines
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Osteoporosis
Pacemaker
Parkinson's Disease
Pinched Nerve
Pneumonia
Polio
Prostate Problem
Psychiatric Care
Rheumatoid Arthritis
Scarlet Fever
Stroke
Suicide Attempt
Thyroid Problems
Tonsillitis
Tuberculosis
Tumors or Growths
Typhoid Fever
Ulcers
Vaginal Infections
Venereal Disease
Whooping Cough
Other Relevant Illnesses
LIFESTYLE
Habits
Smoking
Alcohol
Coffee/Caffeine Drinks
High Stress
Packs/Day
If "Smoking" selected
Alcoholic Drinks/Wk
If "Alcohol" selected
Caffeinated Drinks/Day
If "Caffeine Drinks" selected
Reason for High Stress
If "High Stress" selected
Exercise
None
Moderate
Daily
Heavy
Work Activity
Sitting
Standing
Light Labor
Heavy Labor
INJURIES/SURGERIES
Please describe what happened and when for each injury/surgery below:
Falls
Head Injuries
Broken Bones
Dislocations
Surgeries
MEDICATIONS
Please list any medications you currently take.
ALLERGIES
Please list any allergies you have.
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