• CONFIDENTIAL HEALTH INFORMATION

    All information you supply is confidential. We comply with all federal privacy standards. Please print clearly.
  • Today’s Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you consulted a chiropractor before?
  • Gender
  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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?)
  • Annotate Image (use mouse to draw on diagram). "O" for current condition, "X" for conditions experienced in the past.

  • 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.

  • a. Musculoskeletal
    Rows
  • b. Neurological
    Rows
  • c. Cardiovascular
    Rows
  • d. Respiratory
    Rows
  • e. Digestive
    Rows
  • f. Sensory
    Rows
  • g. Skin
    Rows
  • h. Endocrine
    Rows
  • i. Genitourinary
    Rows
  • j. Constitutional
    Rows

  • 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

  • Surgical interventions, which may or may not have included hospitalization.
    Rows

  • 13. Treatments

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

  • Rows

  • 14. Allergies

  • Are you allergic to any medications?

  • 15. Injuries

  • Have you ever...

  • 16. Family History

  • Rows

  • 18. Social History

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

  • 19. Activities of Daily Living

  • How does this condition currently interfere with your life and ability to function?
    Rows
  • 24. Describe your typical eating habits:
  • 27. Do you wear orthodics?
  • 28. Do you wear a heel lift?
  • 29. Previous chiropractic care?

  • Acknowledgements

  • To set clear expectations, improve communications and help you get the best results in the shortest amount of time, please read each statement and initial your agreement. Click on boxes under Initial columns to type in your initials.
    Rows
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: