CONFIDENTIAL HEALTH INFORMATION

  • CONFIDENTIAL HEALTH INFORMATION

    All information you supply is confidential. We comply with all federal privacy standards. Please print clearly.
  •  - -
  • Have you consulted a chiropractor before?
  • Gender
  •  - -
  • Race
  • Ethnicity
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Smoking Status (age 13 and over)
  • Marital Status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred method of contact?
  • OK to receive text messages?
  • OK to receive email messages?

  • Please describe your Primary Complaint in the space below. Use the Secondary and Additional Complaint boxes if they apply.

  • Primary Complaint

  • And are the result of
  • If an accident or injury
  • Prior interventions (What have you done to relieve the symptoms?)

  • Secondary Complaint

  • And are the result of
  • If an accident or injury
  • Prior interventions (What have you done to relieve the symptoms?)

  • Additional Complaint

  • And are the result of
  • If an accident or injury
  • Prior interventions (What have you done to relieve the symptoms?)

  • 2. How does your current condition interfere with your:

  • 10. Review of Systems
    Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please darken the circle beside any condition that you’ve
    Had or currently Have and initial to the right.

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  • Past Personal, Family and Social History

    Please identify your past health history, including accidents, injuries, illnesses and treatments. Please complete each section fully.

  • Personal History.

  •  11. Personal Illnesses

  • Check the illnesses you have Had in the past or Have now.

  • Rows

  • 12. Operations

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  • 13. Treatments

    Check the ones you’ve received in the Past or are receiving Currently.

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  • 14. Allergies

  • Are you allergic to any medications?

  • 15. Injuries

  • Have you ever...

  • 16. Family History

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  • 18. Social History

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  • Prayer or meditation?
  • Job pressure/stress?
  • Financial peace?
  • Vaccinated?
  • Mercury fillings?
  • Recreational drugs?

  • 19. Activities of Daily Living

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  • 24. Describe your typical eating habits:
  • 27. Do you wear orthodics?
  • 28. Do you wear a heel lift?
  • 29. Previous chiropractic care?

  • Acknowledgements

  • Rows
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  • Should be Empty: